CPC Test Questions and Answers – Medical Coding Certification Online Training Modules With Video Reviews and Printable CPC Mock Test

Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page

2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Click here for more sample CPC practice exam questions and answers with full rationale

November 7, 2019

Compliance Week: Managing Telecommuter Risk

Many healthcare organizations are seeking to reduce expensive physical office space, improve employee morale, and offer flexible options for the workforce; telecommuting has emerged as a commonplace solution for many of us. How can a compliance officer embrace these more prevalent and relevant offsite employee worksite opportunities while still demonstrating they are managing risks to the organization? A less controlled home office environment can be seen as risky, especially in an industry where regular access to member/patient information is often required by employees (and breaches can and do occur).

Many of us, including medical coders and other healthcare business professionals, may find also ourselves on the other side of this equation, where we are the home office telecommuters. We may ponder what we can do to mitigate risks to our members or patients, our organization, and to ourselves at the same time?

Privacy/Security is not the only issue, safety and other regulatory considerations are risk domains that can be compounded by telecommuting employees. Employees working in spaces where the employer is not ensuring Occupational Safety and Health Administration (OSHA), ergonomic, fire, safety, electrical standards, etc. are met (as they would in a corporate office) can create a confusing dilemma. There is often not clear guidance on how the compliance, safety, information security, regulatory, human resources, and legal departments manage the risks for the remote employees to reduce the inherent safety, privacy, security, and other threats.

Telecommuter Risk

Compliance leaders globally have asked if new solutions are needed to address the telecommuter employee. Shareholders are increasingly demanding better assurances from compliance that the organization’s exposure be mitigated. What solutions can better reassure everyone that all telecommuters are working in both a safe and compliant home office environment?

The U.S. Department of Health and Human Services (HHS) holds that covered entities that allow employees to telecommute or work out of home-based offices, and have access to electronic private health information (e-PHI), must implement appropriate safeguards to protect the organization’s data.

While OSHA’s position has wavered on responsibilities for employers regarding the safety of telecommuter home offices, employers still find themselves responsible for the aspects of home-based worksites to minimize other liabilities such as workers compensation cases or tort litigation from damage to employee personal property. Increasing cases of ergonomic injuries such as carpal tunnel syndrome or back strain is also a growing concern.

Compliance Solutions

A combined approach of focused telecommuter attestations, policies, training, surveys, and audit programs maybe a best practice for organizations to consider in addressing the telecommuter employee.

The following are opportunities to consider with telecommuters:

Attestations: On hire into a telecommuter position, annually and/or as advised by your legal counsel, telecommuters can be required to attest to policies and protocols your organization deems necessary in accepting the offsite job responsibility. Employees might slowly transition into a telecommuter (work-at-home) role, and the signing of the attestations might be easily missed. There may also be internal discussions needed to define who is a telecommuter.

There are both off-the-shelf and custom systems that can assist in the automation (assignments, tracking, reporting) of the attestation process, and these might be combined with other annual signature requirements. The attestation can include not only traditional compliance department risks but also safety, human resources, and other areas that you deem important. Part of the attestation might include the agreement to accept a potential unannounced remote work-at-home audit to maintain work-at-home status, and notification that violations may lead to termination of telecommuter status, among other sanctions.

Policies: For those employees transitioning into part-time or full-time telecommuting positions, Mangers may decide to consider reasonable requests from employees to telecommute. The intent is that by offering telecommuting arrangements to staff, managers can better attract and retain qualified team members. Management, with the support and assistance of the human resources and leadership, may develop a policy in which employees can be held accountable, such as requiring:

Telecommuters follow the same organization policies and procedures as onsite employees.
Employees can transition to telecommuting hours based on proven ability to perform the department job responsibilities with little direction.
Employees may be selected to telecommuting jobs based on seniority.
Employees with no current active corrective actions are qualified to telecommute.
Telecommuters must meet technology requirements, such as having high speed internet access available, and are required to use a company router and computer or provide equipment that meets information security requirements,
Telecommuters have a separate home office work area, such as a room separated from other family members by a door, and a shredder to dispose of PHI.
Telecommuters have reasonable ergonomics in place such as a functional workstation and chair.
All cable and electrical cords must be in good repair with no exposed wires or frayed extension and no trip/fall or fire hazards.
The employer reserves the right to inspect the telecommuter work area.

Training: Only a portion of your employee workforce might fall into the telecommuter category. If so, a decision might need to be made whether to integrate work-at-home best practices into the training for all employees or carve out a unique program targeted for that audience. Some companies implement a blended learning approach to telecommuter compliance training and have managers provide in-person training during (or shortly after) new hire orientation, and then assign an online primer or recorded webinar annually.

Online courses can be structured with tabs where certain cohorts of employees will optionally be diverted to a different series of slides.

Other awareness activities, such as intranet posts, Compliance Week handouts, AAPC resources, best practice cases, and brief reminders in regional meetings, might be helpful.

Surveying: Sending surveys to current telecommuters and those to be on-boarded to assess their current work-at-home environment may also be telling for the compliance group in assessing the current situation. If the majority of telecommuters are working in remote satellite locations (such as in member/patient homes, shared spaces in your or other medical facilities and hospitals, health departments, private billing companies, etc.) as opposed to their own personal home, this may present some insights to the type of risks to which they may be exposed.

The surveys may include privacy/security questions to query if telecommuters have, for example, locked file cabinets to protect member written information, a shredder to properly dispose of confidential documentation, a private area for phone discussions where verbal PHI could be disclosed, equipment issued by the organization so computer drives and equipment are properly secured, etc.

Input from the information systems, information security, and other departments may be part of the solution to determine if, for example, the employee has proper internet and secure technology.

Safety questions maybe included to query if telecommuters were have grounded outlets to prevent electrical shock, cables aligned to baseboards to avoid trips and falls, file cabinets are arranged so open drawers do not block exit routes for safe evacuation, workspaces are free from obstructions that would prevent safe visibility and movement, etc.

Surveys with users predefined drop-down menus or yes/no will later be more easily summarized into tables vs. open-ended questions for reporting.

Auditing: The expense of auditing every telecommuter’s home office is generally cost prohibitive depending on the size of the organization and whom you designate formally as a full-time “telecommuter”. However, this does not preclude a small sample audit to gather a collective picture of the various department office spaces that are telecommuting. As important, random audits will send a message to all telecommuters that an audit/inspection could occur at any time.

Auditors might want to audit for telecommuters with desks that are set up in open areas such as living rooms without doors, where other family members and guests can easily overhear conversations where member/patient information, such as diagnosis, is being shared, and require they use a more private location. Also, audits can assist in determining if telecommuters are using your company’s secure portals, assigned equipment (asset tags or serial numbers), have locked file cabinets, shredders, reasonable electrical outlets, and no dangerous conditions. Audits can also be informative in determining if full-time telecommuters are even working at all in a designated home office (shows as working at home, but not home, in the office, nor a satellite location).

Compliance might want to send a notice to the department leader and all employees denoting the photos of the compliance auditors and explain the scenario so that the telecommuter is aware and refuse the auditor entry. Having at least two auditors traveling together might be a best practice in a personal home audit so, for example, a male auditor is not being asked to audit a female’s home office (which may be located in her bedroom). Generally, audits to businesses might be more formally scheduled so to not interrupt business operations and to ensure the office manager is available to answer questions, or if the auditor needs to travel great distance and wants to be more assured the telecommuter is actually home). The auditor can have a checklist designed to ensure consistency in the audits. As much as the auditor can respect the sensitivity of a home office audit, it is suggested to allow the telecommuter a few moments to remove any personal items even if it slightly reduces the validity of the audit so the employees feel it is less of a personal intrusion in their home. Telecommuters who are call representatives might need a few moments to complete a member/patient call or to call their manager to inform them of the reasons for the lapse in productivity.

Reporting: Depending on how the survey and audit was conducted, and systems utilized, reporting back to departments and to various committees can be structured in a variety of ways to inform the company on the findings and recommendations. A listing of telecommuters audited by department and results can often be helpful for department managers on trends and users who need some additional training and guidance. Depending on the severity of any violations, information security, human resources, or the department leader may need to be immediately informed. The majority of the findings that suggest corrections might be dealt with using focused training or consults with compliance and the department leader.

Employ Best Practices

Telecommuters are seen by some organizations as high compliance risks, either by these staff being unaware of protocols or by the nature of the work environment. Education on compliance, privacy, and security policy is a best practice. Compliance professionals can employ several strategies, as outlined in this article, to help mitigate some of the issues inherent with telecommuter staff positions and employ best practices proactively.

Contributors:

Donna Schneider, RN, MBA, CPHQ, CPC-P, CHC, CPCO, CHPC, is a progressive, visionary healthcare executive with demonstrated accomplishments in corporate compliance, privacy, internal audit, managed care contracting, physician relations, and quality improvement. She has comprehensive experience in hospital operations, involvement in inpatient, and ambulatory and physician group practice management in an integrated healthcare delivery system. Donna also has managed care and self-insured employer group health plan experience in conjunction with a messenger model physician delivery network tenure. Schneider has been a member of the HCCA Boston Regional Planning Committee, New England Internal Auditors Conference Board, and the Health Care Finance Administration Board RI/MA. She has also been a mentor for Year Up, Rhode Island since 2018.

Yesenia Contreras, MHA, CIC-I, has 24 years of experience in the healthcare industry. Her proficiency includes developing and implementing audit and education activities required to comply with federal guidelines and other compliance related requirements. Contreras’ expertise includes working with regulations that govern the activities of outpatient physician services, behavioral health services, and community practices. In addition, she strives to increase and strengthen healthcare providers’ awareness and understanding of medical record documentation guidelines and coding principles.

Mark Schneider

Mark Schneider, MBA, CPCO, is a compliance professional with experience in the provider and payer space who has conducted telecommuter home office audits, as well as those at practices and hospitals. He holds numerous compliance, privacy, fraud, and research certifications, is a certified medial first responder/EMT, and enjoys supporting organizations and the local community in his endeavors.

Latest posts by Mark Schneider (see all)

AAPC’s annual salary survey gives a good understanding of the earning potential within the medical coding profession.
See what actually is going on in the healthcare business job market.

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 6, 2019

To 22 or Not to 22?

When and how to use this modifier appropriately, that is the question.

Surgeons work hard, so when they perform beyond the “typical” hernia repair or the not-so-usual third meniscal repair, a higher reimbursement is warranted. Appending modifier 22 Increased procedural services to the surgical code tells the payer the surgeon went above and beyond the standard call of duty and would like to be paid for it. That’s all well and good, but payers want proof.

Proof comes in the form of documentation. As a coder, however, it’s difficult to judge when a surgeon has performed increased procedural services, and even harder to get the claim paid if the work isn’t documented appropriately.

Part of your job is to serve as a conduit between the surgeon and payer. To get modifier 22 paid, you need to know when it’s appropriate to use it, what the payer wants as proof, and how to get it.

Determine the Appropriateness

Neither an extra 5 minutes of surgical time nor performing difficult but standard components of a procedure is an “increased service.” Medicare Administrative Contractors (MACs) all agree that modifier 22 is used to identify “substantial” additional work, but none define what that term means to them, specifically. There are, however, very specific do’s and don’ts.

Do append modifier 22:

When documentation clearly indicates the difficulty of the procedure beyond the norm, including complications or medical emergencies
When another CPT® code wouldn’t better describe the additional work
When the surgical procedure code has a 0, 10, or 90-day global period

Do not append modifier 22 to:

A surgery code if the surgeon did not give supportive detail of the increased procedural service
Indicate that the procedure was performed by a specialist. Specialty designation alone does not warrant the use of modifier 22.
Report increased an evaluation and management (E/M) service. For additional time outside of the typical E/M service, see the prolonged care codes.

Document in Detail

Modifier 22 tells the payer, “I deserve to be paid more than the code’s relative value unit.” That’s going to take some convincing.

If the procedure was difficult, the documentation must explain in detail why it was difficult. Was the patient’s condition severe? If so, how severe? And why? If the procedure took considerably more time than usual, documentation must explain how much additional time was spent and why.

Good example: “I spent an additional 20 minutes excising multiple adhesions from a prior surgery before I could begin the standard surgery.”

Bad example: “This procedure took 20 minutes longer than usual.”

Reasons for additional work, according to Noridian Healthcare Solutions, include:

Increased intensity
Time
Technical difficulty of procedure
Severity of patient’s condition
Physical and mental effort required

Details of the procedure should be included in the body of the operative note. The reason for the difficulty is more subjective and should be included in either the “summary” or the “findings” area of the operative report. The additional time versus the average time for the procedure should be included, as well, either in the summary or findings of the procedure section, or within the body of the operative report. Noridian requires documentation to include a separate paragraph titled “Unusual Procedure.” Palmetto GBA also requires a concise statement and operative report, clearly identified either in the electronic documentation or the operative report. Go online to check your payer’s specific instructions for using modifier 22.

Bottom Line

Modifier 22 is one of those over-utilized modifiers that sends up red flags to payers, which is why MACs consider these claims individually. Using modifier 22 correctly is not enough to get a claim paid. Proper documentation is key. When everyone knows what is expected of them, the result is cleaner claims and proper, timely reimbursement.

About the author:

Sherrie Lynne Anderson, MS, CPC, CPC-I, CPPM, coding compliance manager of Plastic Surgery and Acute Critical Care Surgery (Trauma) Washington University School of Medicine. She has 20 years of experience working in the healthcare industry, including managing coding, billing, compliance, and aspects of the revenue cycle; and her specialty experience is in pediatrics, orthopedics, and neurology. Anderson received a Master of Science in Healthcare Administration from Lindenwood University. She serves as Region 5 – Southwest representative of the AAPC National Advisory Board, is a member of the St. Louis East, Mo., local chapter, and has served as an officer for many years.

Resources:

https://med.noridianmedicare.com/web/jeb/topics/modifiers/22

www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-B~8EEL8Y3466

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 5, 2019

Get a Global Perspective on Orthopedic Fracture Care Coding

Help physicians and patients understand exactly what it all means.

One of the most asked questions coders get from patients at an orthopedic practice is: “Why is there a surgical code on my bill for an office visit?” It’s a valid question coming from a patient who was seen in the clinic, treated for a fracture, then later received their explanation of benefits (EOB) statement with a surgical procedure costing around $1,000.

To help providers and patients understand fracture care global billing, let’s review the correct process for coding, provider documentation tips, and information you can provide patients regarding why they are billed such a high-cost code for a clinic visit.

Options for Coding Fracture Care Visits in the Office

A patient arrives at the clinic with an injury that is evaluated and X-rayed. The provider discusses the treatment options appropriate for the level of severity. If the fracture is severe enough, the patient might have to be scheduled for surgery; however, if the fracture is minor and can be treated non-surgically in the clinic, the provider has two options for reporting this patient’s visit. The options are shown in Table A.

Table A: Coding options for nonsurgical fracture care

Global Fracture Care	Non-global Fracture Care
99203-57	99203-25
Closed treatment code (includes casting)	Casting CPT® (initial +2)
Supplies	Supplies
X-rays	X-rays
Follow-up Visits Post Global Fracture Care	Follow-up Visits Post Non-global Fracture Care
Casting CPT® (2 casts) using modifier 58	Approx. 1-3 more visits
Supplies	99213
X-rays	Casting/supplies, X-rays

If the provider chooses to bill a global code for the initial procedure, then they can bill for the initial evaluation and management (E/M), casting supplies, and X-rays. Any visit after this will be a post-op visit, and the casting with modifier 58, supplies, and X-ray will be billable.

If the provider chooses to bill non-global, then the E/M, casting, casting supplies, and X-rays are billed for the initial visit and all subsequent visits.

The first cast is inclusive to the global surgical CPT® code, but re-applications are billable. If a reduction of the fracture is done in the clinic, then it would be appropriate to use the closed treatment global code with or without manipulation.

Proper Documentation for Fracture Care Is Key

To support a global fracture care CPT® code, the provider must document that the patient received “definitive fracture care.” This is where it can get confusing.

If your provider chooses to bill a closed treatment fracture care code, ask yourself the following questions:

Did the provider put a plan into place for follow-up treatment?
Was an immobilization device provided?
Was medication/pain management provided?

If the answer to any of these questions is yes, the closed treatment code is billable for fracture care management.

Important: When billing a closed treatment code, do not code the cast/splint application. You cannot bill the patient for both.

Work with your clinic management staff to create a policy for coding fracture care, and make sure everyone understands the policy — including the patient. You do not want an upset patient contacting the billing department asking why a surgery charge is on their clinic bill. If the patient is made aware ahead of time that the charge will encompass casting/splint for that day, as well as subsequent office visits within the global period, you have reduced the chances for any billing surprises.

About the author:

Jodi Hassinger, CPC, COSC, is a lead coder with TRIA Orthopedics in Bloomington, Minn. She has over 27 years’ experience in the healthcare field, with many years in the orthopedic department. Hassinger has held offices of secretary and vice president for the St. Paul, Minn., local chapter and was the chapter’s Member of the Year in 2017.

Resource:

Outsource Strategies International. Orthopedic Medical Coding Ideas for Closed Treatment of Fractures without Manipulation: www.outsourcestrategies.com/blog/orthopedic-medical-coding-ideas-closed-treatment-fractures.html

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 3, 2019

Death of the Documented History, Rise of the Patient Advocate

When clinical documentation gets overrun with auto-populated data, it’s time to redirect technology to better serve our patients.

Medical providers will no longer be required to document the history/medical interview during outpatient/office services in health records starting Jan. 1, 2021, per the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This new policy is supported by the Centers for Medicare & Medicaid Services’ (CMS) Patients Over Paperwork Initiative, which seeks to reduce medical provider administrative burden and improve the healthcare experience for all participants, including patients.

Removing requirements to document the history in the health record can sound contradictory to excellent care. Sir William Osler, MD, considered to be the father of modern medicine, said, “Listen to the patient, he is telling you the diagnosis.” Osler’s words ring true today, as studies show an accurate diagnosis and effective treatment plan are likely to come from understanding the patient’s concerns and presenting symptoms.

Auto-populated Data Muddles the Patient History

Unfortunately, our current system, which rewards quantity of data rather than quality, has forced medical providers to auto-populate electronic health record (EHR) content using templates and copy-and-paste and copy-forward functions. As a result, data documented in the health record often has little to do with the patient encounter. Worse yet, auto-populated data often includes patient information that was never obtained or contradicts other statements in the health record. Two studies in medical literature showcase the poor status of health record documentation.

Study No. 1

The first article, published March 2017 in the Journal of the American Medical Association (JAMA) Ophthalmology compared what patients reported in the waiting room of a university eye clinic to what medical providers documented in the EHR.

Investigators asked patients in the waiting room to voluntarily complete a survey with eight questions that matched a screenshot from the provider’s EHR. The eight questions addressed eye concerns from “blurry vision” to “eye pain.” The questions addressed the presence/absence of each symptom using a Likert-type rating scale of severity from “very mild” to “very severe.” Investigators collected the forms before patients exited the waiting room to see the doctor. Later, researchers compared each patient’s waiting room report to the provider’s documentation in the EHR.

When patients reported “eye pain” in the waiting room, researchers found “eye pain” to be missing from documentation 29.5 percent of the time. When patients reported three or more concerns, zero charts in the entire study documented the three or more concerns. Investigators counted any mention of the eight eye concerns in the health record for the date of service. This included clicking a button next to any of the concerns in the provider’s history that identified the presence of the problem, as well as any free-text descriptions. The study revealed a poor correlation between what patients reported and what providers documented into the health record.

The JAMA eye study concluded, “These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive resource for clinical practice or ‘big data’ research.”

Study No. 2

Another JAMA study, published Sept. 18, 2019, monitored medical residents in the emergency department and compared patient encounters with EHR documentation. Investigators shadowed physicians as they interacted with patients and then reviewed EHRs, with attention to the history’s review of systems (ROS) and the examination. Researchers combined audio recordings and live observation comments to best quantify what occurred during the physician-patient encounter. To score the ROS, investigators created a checklist based on CMS publications.

The study explains, “If a symptom mentioned in the encounter was not listed on the checklist, the reviewer added the symptom to the encounter’s checklist under the most relevant body system.” The study further explains, “Reviewers extracted all symptoms listed as reviewed in either the ROS or the history of present illness portions of the electronic medical record and assigned them to a body system using the same checklist as in the ROS observation measurement.”

The JAMA emergency department study found the ROS to have a 40.1 percent accuracy rate. If scribes were involved, ROS accuracy dropped to 36.7 percent. The study concluded, based on poor documentation accuracy, that “payers should consider removing financial incentives to generate lengthy documentation.”

Physician Leaders Are Called to Action

During an @SeemaCMS Twitter podcast, July 18, 2018, National Coordinator for Health Information Technology Donald Rucker, MD, was asked if eliminating provider requirements to document the history in health records would undermine patient care and efforts to create effective predictive algorithms. Rucker defended new CMS policies, calling health record documentation of the history/exam “anti-matter” and “clutter.” Citing the need for greater “signal” and less “noise,” he calls for the end of templates and copy-and-paste and copy-forward EHR functions.

A 2017 Journal of the American Osteopathic Association (JAOA) paper invited patients to complete a PreHistory (PreHx) in preparation for a medical encounter with the family doctor. Patients were sent a three-page form that included all of the near 30 history questions as defined by CMS’ 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. Upon arriving at the office, patients presented the document as a written request to amend the record per the Standards for Privacy of Individually Identifiable Health Information of 2001, commonly referred to as the HIPAA Privacy Rule. Rather than wait up to 90 days to review the patient’s request to amend, the provider followed a research protocol to accept the information immediately and use the patient’s words to populate the history component of the health record. As a result, accuracy rose to 100 percent for the chief complaint, history of present illness, status of chronic conditions/diseases, ROS, and past, family, and social histories.

Use of a PreHx allowed:

The patient to fully disclose all their concerns and paint a comprehensive picture of their problem into the health record.
The provider to have the entire history documented in the encounter note before entering the exam room.
Efficient data gathering for the provider to review the patient’s story and ask deeper questions beyond the documentation guidelines and then perform a pertinent examination.

Because both the patient and provider were highly engaged, medical decision making (MDM) readily transformed into shared decision making. The study held to a 15-minute schedule for all patients and use of the PreHx permitted all charts to be completed by the end of the face-to-face visit. Per the JAOA’s research protocol, all PreHx patients received a printed copy of the entire encounter note (history, exam, MDM) at the checkout window at the end of the visit.

CMS declared for 2019 that patients and ancillary staff members may document the history into health records. This provision relieves providers of the impossible task of asking and documenting time-consuming history data and removes the temptation to auto-populate EHR content with templates and automated functions. The patient, after all — often supported by family members, friends, and caregivers — knows the subjective medical history better than anyone.

Technology Moves Toward Improving Patient Outcomes

As we enter the digital age of healthcare, we must leverage technology to improve our ability to diagnose and treat patients. EHR systems will soon provide feedback to guide us toward best practices. Imagine viewing three treatment options and seeing the expected outcome success rate next to each option? Just as Amazon can suggest another product or Netflix can suggest a movie, EHR systems will soon interact with the user. The data in EHR systems, however, must be accurate.

The death of the provider-documented history should not be mourned. For the provider, we are relieving stenography and basic data entry duties in favor of maximizing critical thinking and decision making. For patients, the new rule empowers individuals to control the narrative documented in their health record. Fostering the patient-provider relationship, new policies encourage patients to be heard and providers to understand. Death of the provider-generated history gives rise to patients being their own advocate, ushering a new age in healthcare.

Resources:

Silverman, ME, Murray TJ, Bryan CS, “The Quotable Osler,” American College of Physicians, 2008, p98

Federal Register, 2019 Medicare Physician Fee Schedule final rule, Nov. 23, 2018, www.federalregister.gov/public-inspection/2018/11/23

JAMA Ophthalmology, “Agreement of Ocular Symptoms Reporting Between Patient-Reported Outcomes and Medical Records, March 2017, www.ncbi.nlm.nih.gov/pubmed/28125754,

JAMA, “Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior?” Sept. 18, 2019, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388

JAOA, “Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law, 2017, https://jaoa.org/article.aspx?articleid=2599978

CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

HIPAA Privacy Rule, The Standards for Privacy of Individually Identifiable Health Information of 2001, 45 CFR § 164.526

Dr. Michael Warner

Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow, is an associate professor at Touro University California, president of non-profit Patient Advocacy Initiatives, alternate advisor on AMA RUC, and an AAPC National Advisory Board member. At Touro, he is conducting a series of research projects with the online tool www.PreHx.com to determine evidence-based best practices to accommodate a patient-authored medical history and improve data gathering flow.

Latest posts by Dr. Michael Warner (see all)

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 2, 2019

Your Guide to Specialty Society Webpages

Refine your craft by consulting these insightful medical coding resources.

As a coder striving to be the best version of yourself, you’re probably constantly scouring the internet for any and all available resources that can help you polish your skills. Outside of the usual suspects, such as your code books and code lookup tools, these outside resources may include message boards, the Centers for Medicare & Medicaid Services (CMS), commercial payer websites, and AAPC’s Knowledge Center and forums.

There’s one incredibly useful resource, however, that’s often overlooked by the coding community — specialty societies. The common misconception surrounding specialty societies (also known as member organizations), is that they exclusively cater to physicians and advance practice providers (APPs). On the contrary, specialty societies offer an invaluable array of coding and practice management information that you’d be hard-pressed to find elsewhere online.

Seeking out your specialty society is only half the battle, though. Unless you know exactly how to navigate the sometimes-harsh terrain of these websites, you may not be able to fully actualize their potential. Fortunately, the structure of these websites is relatively uniform in their design. This means that if you can navigate one website, you can navigate them all.

Get to Know Your Specialty Society

National medical specialty societies typically go by one of four titles:

American Academy
American Association
American College
American Society

For instance, there’s the American Academy of Family Physicians (AAFP) and the American College of Radiology (ACR). The first thing you may notice when browsing the entirety of nationally recognized specialty societies is that there may be up to four or five existing societies dedicated to the same specialty or subspecialties. The orthopedic specialty, for example, includes the American Academy of Orthopaedic Surgeons (AAOS), the American Orthopaedic Association (AOA), and the American Orthopaedic Foot and Ankle Society (AOFAS).

Understand the Layout of Your Specialty Society’s Website

Specialty society webpages are typically broken down into professional service (physician-oriented) and practice management components; however, it’s not always easy to tell the difference based on the “tabs” available at the top of the page. Some specialty organizations, such as the American Academy of Otolaryngology — Head and Neck Surgery (AAO-HNS), separate tabs by professional development and practice management; this allows for easy access if you’re exclusively looking for information geared toward one or the other.

More often than not, specialty society webpages require a little more digging to reach the portion of the website dedicated exclusively to coding and/or practice management. To expedite the search process, you’ll want to get a good feel for what each tab is referring to — because it’s not always clear-cut. Refer to a few of the main tabs at the top of the webpage for the AAOS (www.aaos.org) as an example:

Periodicals
Education
Quality
Research
Advocacy

At first glance, it’s almost impossible to tell where the coding or practice management-related information is located. Let’s break down each tab piece by piece for a better understanding of what you’re looking at:

Periodicals Section

While some specialty societies link their respective journal in this tab, the AAOS includes much more than just the Journal of the AAOS. You’ll also find a tab for AAOS Now, which is a monthly digital magazine geared toward physicians, coders, and practice managers. You can even apply a filter to the massive archive of articles to narrow the search for articles exclusively related to “Practice Management” or “Quality & Research.” The AAOS includes two additional resources: the Orthopaedic Knowledge Online Archive (OKOJ) and Clinical Orthopaedics and Related Research (CORR).

Disclaimer: You’ll find that, despite signing up for a membership, you’ll be locked out of most articles featured in AAOS Now. That’s because the AAOS, along with some other specialty societies, may include your membership (as a coder) in the “nonmember” category. Unless you’re registered as a physician, resident, or (sometimes) APP, your access to certain features, such as AAOS Now, may be restricted. In these cases, your best plan of action is to inquire with your physician(s) about gaining access to restricted resources via their membership.

Education Section

On some specialty society webpages, you’ll find a standalone Education tab — as is the case with the AAOS. On the AAOS webpage, the Education tab links to a variety of subsections such as continuing education, certification, specialized areas of interest, patient education, and practice management. On other specialty webpages, you may find an extra set of tabs including these components in place of an all-encompassing Education tab. On the AAOS webpage, the Practice Management subsection is comprehensive enough that it may fare better as its own separate tab. Here, you’ll find a treasure trove of practice resources on subject matters including coding and reimbursement.

If you’re interested in pursuing all things related to coding and reimbursement within the orthopedic specialty, click on Practice Management under Education Focus and then click on Coding and Reimbursement under Member Resources in the navigation box on the left. Here, you’ll find numerous avenues to pursue, some of which involve paying for third-party coding tools, courses, and resources. If you’re looking to expand your knowledge of coding and reimbursement, the area that will be of most interest to you is the AAOS Now Coding Article Archive.

Quality Section

The Quality section of most specialty societies includes Merit-based Incentive Payment System (MIPS) quality performance measures, appropriate use criteria (AUC), and clinical practice guidelines (CPGs). From a coding and practice management perspective, you’ll want to stay on top of all updates to CPGs and MIPS measures as they relate to your respective specialty.

CPGs and clinical consensus statements (CCSs), for instance, can be useful in appealing claims denied due to lack of medical necessity. Some practices will submit CPGs and CCSs with paper claims involving the use of an unlisted code. For example, a recent CCS published by the AAO-HNS titled Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube (BDET) has been successfully utilized by otolaryngology practices for justification when performing a BDET on patients with obstructive eustachian tube dysfunction.

Research Section

You might think CPGs and CCSs are better suited under the Research tab of your specialty society webpage, but those sections are usually reserved for active and completed research studies, in addition to research opportunities presented to clinicians. Some specialty societies may opt to include their respective journals or clinical publications under this tab, as well.

Advocacy Section

The Advocacy tab focuses on state and federal legislative and regulatory issues involving the given specialty. Federal issues, as described on the AAOS webpage, include topics as broad as the Affordable Care Act and health information technology. State issues may vary in scope and size as compared to federal issues, but the general concept is the same as to how specialty societies address and advocate for or against them.

Access a list of American Medical Association-recognized specialty societies.

Trust This Expert Advice

The next time you’re scouring the internet for coding or practice management advice, navigate to your specialty society. If you’re wondering whether your specialty society’s guidance is authoritative enough for you, you’ll be pleased to know that the American Medical Association and CMS routinely channel their own guidelines and AUC based on guidance from specialty societies.

While specialty society guidance should never take the place of your code books, it should be an integral component to the rest of the coding resources you’re already utilizing.

Brett Rosenberg

Brett Rosenberg, MA, CPC, COC, CCS-P, serves as the editor of The Coding Institute’s (TCI’s) Radiology, Otolaryngology, and Outpatient Facility Coding Alerts. He earned his bachelor’s degree in psychology from the University of Vermont in 2011 and his master’s degree in psychology from Medaille College in 2016. Rosenberg is affiliated with the Flower City Professional Coders local chapter in Rochester, N.Y.

Latest posts by Brett Rosenberg (see all)

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 2, 2019

What Radiologists Need to Know About ICD-10 Changes for 2020

What Radiologists Need to Know About ICD-10 Changes for 2020 The 2020 annual update to the ICD-10-CM^[i] system used in medical insurance claim billing became effective on October 1, 2019. Twenty-one (21) codes were deleted, thirty (30) codes were revised and 273 new codes were added. The good news for radiologists is that relatively few of these changes will affect your work.

The guidelines for use of the system include a general warning not to use terms that convey uncertainty, such as “probable”, “suspected”, “questionable”, “rule out”, or “working diagnosis”. To this list have been added the terms “compatible with” and “consistent with”.

The codes that have been deleted fall into the following categories:

Vertigo
Atrial fibrillation
Congenital conditions
Ehlers-Danlos syndrome
ADA deficiency
Heatstroke or sunstroke

If a patient exam is presented with the need to use a diagnosis code in one of these areas, further investigation into the coding should be made. Otherwise, you do not need to worry about using outdated codes.

New codes have been added for reporting in the Genitourinary System:

Unspecified lump in the breast, overlapping quadrants
Right breast	N63.15
Left breast	N63.25
Post endometrial ablation syndrome	N99.85

New codes have been added for reporting in the Circulatory System:

Phlebitis and thrombophlebitis of the:
Right peroneal vein	180.241
Left peroneal vein	180.242
Peroneal vein, bilateral	180.243
Unspecified peroneal vein	180.249

Right calf muscular vein	180.251
Left calf muscular vein	180.252
Calf muscular vein, bilateral	180.253
Unspecified calf muscular vein	180.259

Acute embolism and thrombosis of the:
Right peroneal vein	182.451
Left peroneal vein	182.452
Peroneal vein, bilateral	182.453
Unspecified peroneal vein	182.459

Right calf muscular vein	182.461
Left calf muscular vein	182.462
Calf muscular vein, bilateral	182.463
Unspecified calf muscular vein	182.469

Twenty-five (25) codes were added to describe various fractures of the orbit or orbital roof:

Fracture of orbital roof,	left side	right side	unspecified side
Initial encounter for closed fracture	S02.122A	S02.121A	S02.129A
Initial encounter for open fracture	S02.122B	S02.121B	S02.129B
Subsequent encounter for routine healing	S02.122D	S02.121D	S02.129D
Subsequent encounter for fracture with delayed healing	S02.122G	S02.121G	S02.129G
Subsequent encounter for fracture with nonunion	S02.122K	S02.121K	S02.129K
Sequela	S02.122S	S02.121S	S02.129S

Fracture of orbit, unspecified side
Initial encounter for closed fracture	S02.85XA
Initial encounter for open fracture	S02.85XB
Subsequent encounter for routine healing	S02.85XD
Subsequent encounter for fracture with delayed healing	S02.85XG
Subsequent encounter for fracture with nonunion	S02.85XK
Sequela	S02.85XS
Fracture of lateral orbital wall, unspecified side, sequela	S02.849S

Finally, seven (7) codes were added to describe the types of Ehlers-Danlos syndrome and other congenital conditions to replace some of the deleted codes.

Generally, of greater impact than the ICD coding changes is the annual revision of the Current Procedural Terminology (CPT) system that takes effect at the beginning of each year. Watch for our full coverage of the important coding changes for radiology. Subscribe to this blog to keep abreast of these issues and other news that affects your practice.

[i] ICD stands for International Classification of Diseases, the system owned and copyrighted by the World Health Organization that is used to report diagnoses when submitting claims for reimbursement of physician services, among many other purposes. ICD-10 is the 10th edition of this coding system. CM stands for the Clinical Modification of the classification system.

Recent Articles

“Closing the Loop”: What Radiologists Should Know About Software

Keeping Your Practice Independent – Build on Existing Relationships

Lessons Learned – Incidental Findings in Radiology

Follow HAP on LinkedIn

Follow HAP on Twitter
Like HAP on Facebook

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

November 1, 2019

I Am AAPC: Jingmei Chen, MBA, CPC, CPB

After earning my Master of Business Administration degree, I worked in the financial field until about three years ago, when I reached a turning point in my career. Healthcare business has always been a long-distance dream for me; and after seeing an AAPC coding course advertisement in a magazine, I decided to give it a try.

Change Is Always Better

My data science teacher once mentioned that switching choices often improves our chances of winning. But jumping from industry to industry and starting something new from scratch is not always easy. Luckily, AAPC provides comprehensive resources for new members, which made me feel at home.

Instead of a degree program, I enrolled in AAPC’s online course for my exam preparation. The courses and practice exams were easy to navigate, interactive, and flexible. It prepared me to take the exam with confidence, and without a medical background. I was able to complete the courses and passed the Certified Professional Coder (CPC®) exam, and then the Certified Professional Biller (CPB™) exam, on my first tries, all within six months.

Stay Current

To get a clear idea of what it is like to be a medical coder, I read carefully every edition of Healthcare Business Monthly, which helps me tremendously to get used to medical lingo and receive industry updates. I also participate in local chapter meetings, which provide me with great networking opportunities with industry veterans. I listen to what they have to say about their work and ask questions.

The overall learning process through AAPC has helped me to pass my exams and has prepared me to enter a new industry successfully. For that, I am very grateful.

Perseverance Will Serve You Well

Getting certified is a good start, but without actual coding and billing experience in a medical setting, it is not always easy to land a coding job. I kept trying: I enrolled in AAPC’s Practicode and gained valuable hands-on, real-world coding experience, and I volunteered in a local hospital as an administrative assistant. About a year after I earned my certificates, I was able to land a billing job in a local practice.

Today, I am a revenue management analyst at a hospital in Florida. I enjoy working with my team and learning from everyone; it helps me to connect the dots with old and new knowledge and to gain a better understanding of the entire medical business.

Excited for the Future

New technology and healthcare demands are changing the industry dramatically; there seem to be endless new ideas to increase efficiency and accuracy, which will translate into a more tech-savvy healthcare workforce. I am very excited to be part of this change and to continue learning.

I plan to start preparing for the Certified Professional Medical Auditor (CPMA™) exam to further integrate my knowledge as a healthcare business professional.

#IAMAAPC

Renee Dustman

Executive Editor at AAPC

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications – Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

Latest posts by Renee Dustman (see all)

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

October 31, 2019

Pharmaceutical Compounding Chapter Revisions on Hold

But for how long, nobody knows.

Allergy, otolaryngology and primary care practices can breathe a sigh of relief, as the new Compounding Pharmacy USP standards set to go into effect Dec. 1, 2019, have been postponed as a result of appeals.

The revisions to Chapters <795> Pharmaceutical Compounding – Nonsterile Preparations and <797> Pharmaceutical Compounding – Sterile Preparations, as well as new Chapter <825> Radiopharmaceuticals – Preparation, Compounding, Dispensing, and Repackaging, are on hold until further notice.

General Chapter <800>, which describes requirements and responsibilities of personnel handling hazardous drugs; facility and engineering controls; procedures for deactivating, decontaminating, and cleaning; spill control; and documentation, is still on track for implementation on Dec. 1, 2019.

Key topics covered in the appeals to <795> and <797> included:

Beyond-Use Date (BUD) provisions in both chapters,
Removal of Alternative Technology provision from <797>, and
Applicability of and to veterinary practitioners in both chapters.

These standards affect medical practices that provide allergy serum because the mixing of the allergy serum is considered compounding pharmacy work. The sterile preparations outlined in the new standards are very detailed and overly burdensome for practices that only mix antigens and dilutant to create allergy immunotherapy.

For now, the USP will maintain the BUD framework for compounded nonsterile preparations in <795> and maintain provisions for compounded sterile preparations in <797>. The USP will also reinstate the Alternative Technology provision in <797>, which states:

“The use of technologies, techniques, materials, and procedures other than those described in this chapter is not prohibited so long as they have been proven to be equivalent or superior with statistical significance to those described herein.”

Although reinstated, the USP says “the Alternative Technology provision is not intended to permit BUD extension or to extend the time during which single-dose containers may be used.”

Plan Ahead

At the Administrator Support Community for Ear Nose and Throat (ASCENT) Annual Meeting in Austin, Texas. Sept. 8-12, MedAllergy, a pharmacy that provides nondiluted allergenic extract, provided a summary of the new standards currently on hold:

Personal Qualifications:

A designated person with training and expertise in allergen immunotherapy is responsible for ensuring that personnel who will be preparing allergen immunotherapy are trained, evaluated, and supervised.
Before beginning to independently prepare allergen extracts, all compounding personnel must complete training and be able to demonstrate knowledge of theoretical principles and skills for sterile compounding.
Annual personnel training and competency must be documented. Personnel must demonstrate proficiency in these procedures by passing a written or electronic test before they can be allowed to compound allergenic extract prescription sets.
Before being allowed to independently compound, all compounders must successfully complete gloved fingertip and thumb sampling on both hands, no fewer than three separate times. Each fingertip and thumb evaluation must occur after performing separate and complete hand hygiene and garbing procedures. After the initial competency evaluation, compounding personnel must successfully complete gloved fingertip and thumb sampling at least every 12 months thereafter.
Compounding personnel must have their sterile technique and related practices evaluated ever 12 months as demonstrated by successful completion of medial-fill test.
Personnel who fail competency evaluations must successfully pass re-evaluation in the deficient area(s) before they can resume compounding of allergenic extract prescription sets. The designated person must identify the cause of failure and determine appropriate re-training requirements.
Personnel who have not compounded an allergenic extract prescription in more than 6 months must be evaluated in all core competencies before resuming compounding duties.

Gloved and Fingertip and Thumb Sampling Procedures:

Use one sampling device per hand (eg: plates, paddles or slides) containing general microbial growth agar (eg: trypticase soy agar (TSA)) supplemented with neutralizing additives (e.g., lecithin and polysorbate 80) as this agar supports both bacterial and fungal growth.
Label each sampling device with a personnel identifier, whether it was from the right or left hand and the date and time of sampling.
Do not apply sterile 70% isopropyl alcohol (IPA) to gloves immediately before touching the sampling device because this could cause a false-negative result.
Use a separate sampling device for each hand, collect samples from all gloved fingers and thumbs from both hands by rolling fingers pads and thumb pad over the agar surface.
Incubate the sampling device at temperature of 30-35 degrees Fahrenheit for no less than 48 hours and then at 20-25 degrees Fahrenheit for no less than five additional days. Store media devices during incubation to prevent condensate from dropping onto the agar and affecting the accuracy of the cfu reading (eg: invert plates)
Record the number of cfu per hand (left hand and right hand)
Determine whether the cfu action level is exceeding by counting the total number of cfu from both hands.

Gloved Fingertip and thumb sampling action levels:

Initial sampling after garbing: >0

Subsequent sampling after media-fill testing (every 6 months): >3

Media-Fill Testing Procedures:

If all of the starting components are sterile to begin with, manipulate them in a manner that simulates sterile to sterile compounding activities and transfer the sterile soybean-casein digest media into the same types of container-closure systems commonly used at the facility. Do not further dilute the media unless specified by the manufacturer.
If some of the starting components are nonsterile to begin with, use a nonsterile soybean-casein digest powder to make a solution. Dissolve nonsterile commercially available soybean-casein digest medium in nonbacteriostatic water to make a 3% nonsterile solution. Manipulate it in a manner that simulates nonsterile to sterile compounding activities. Prepare at least one container as then positive control to demonstrate growth promotion which is indicated by visible turbidity upon incubation.
Once the compounding simulation is completed, the final containers are filled with test media, incubate them in incubator for seven days for 20-25 degrees Fahrenheit followed by seven days at 30-35 degrees F to detect a broad spectrum of microorganisms.
Failure is indicated by visible turbidity or other visual manifestations of growth in the media in one or more container closure unit(s) on or before 14 days.

Personal Hygiene and Garbing:

Before beginning compounding of allergen immunotherapy prescription sets, personnel must perform hand hygiene procedures and garbing procedures according to the facility Standard Operating Procedures (SOPs)
The minimum garbing requirements include:

a. Low-lint garment with sleeves that fit snugly around the wrists and that is enclosed at the neck (eg: gowns or coveralls)

b. Low-lint disposable cover for head and that covers hair and ears and if applicable, disposable cover for facial hair

c. Face mask

d. Sterile, powder-free gloves

3. Compounding personnel must rub 70% IPA onto all surfaces of the gloves and allow them to dry thoroughly throughout the compounding process.

Facilities:

The compounding process must occur in an ISO Class 5 PEC or in a dedicated allergenic extracts compounding area (AECA). The PEC or AECA used to compound prescription sets must be located away from unsealed windows, doors that connect to the outdoors and traffic flow, all of which may adversely affect air quality. Neither a PEC nor an AECA may be located where environmental challenges (eg: restrooms, warehouses or food preparation areas) could negatively affect air quality. The PEC or the work surfaces in the AECA must be located at least 1 meter away from a sink. The impact of activities that will be conducted around or adjacent to the PEC or AECA must be considered carefully when designing such an area.

a. If used, the PEC must be certified every 6 months

b. If used, a visible perimeter must establish the boundaries of the AECA.

i. Access to the AECA during compounding must be restricted to authorized personnel.

ii. During compounding activities, no other activity is permitted in the AECA.

iii. The surfaces of ceilings, walls, floors, fixtures, shelving, counters and cabinets in the AECA must be cleanable.

iv. Carpet is not allowed in the AECA.

v. Surfaces should be resistant to damage by cleaning and sanitizing agents.

vi. The surfaces in the AECA upon which the allergenic extract prescription sets are prepared must be smooth, impervious, free from cracks and crevices, and non-shedding to allow for easy cleaning and disinfecting.

vii. Dust-collecting overhangs such as utility pipes, ledges, and windowsills should be minimized. If overhangs or ledges are present, they should be easily cleanable.

viii. The AECA must be designed and controlled to provide a well-lighted working environment with temperature and humidity controls for the comfort of compounding personnel wearing the required garb.

Cleaning and Disinfecting:

In a PEC, all interior surfaces of the PEC must be cleaned and disinfected daily and when surface contamination is known or suspected. Apply 70% IPA to the horizontal work surface between each prescription set.

2. In an AECA, all work surfaces in the AECA, where direct compounding is occurring must be cleaned and disinfected daily and when surface contamination is known or suspected. Apply 70% IPA to the horizontal work surface between each prescription set.

a. If present, walls, doors and door frames within the perimeter of the AECA must be cleaned or disinfected monthly and when surface contamination is known or suspected.

b. Ceilings within the AECA must be cleaned and disinfected when visibly soiled and when surface contamination is known or suspected.

3. Vial stoppers on packages of conventionally manufactured sterile ingredients must be wiped with 70% IPA to ensure that the critical sites are wet and allowed to dry before they are used to compound allergenic extracts prescription sets.

Establishing Beyond Use Dates (BUD):

The BUD for the prescription set must be no later than the earliest expiration date of any allergenic extract or any diluent that is part of the prescription set, and the BUD must not exceed one year from the date the prescription set is mixed or diluted.

Labeling:

The label of each vial of an allergenic extract prescription set must display the following prominently and understandably:

a. Patient name

b. Type and fractional dilution of each vial, with corresponding vial number

c. BUD

d. Storage condition

Shipping and Transport:

If shipping or transporting allergenic extract prescription sets, compounding personnel must select modes of transport that are expected to deliver properly packed prescription sets in an undamaged, sterile and stable condition.Inappropriate transport can adversely affect the quality of the allergenic extract prescription sets.
When shipping or transporting allergenic extract prescriptions that require special handling, personnel must include specific handling instructions on the exterior of the container.

Documentation:

All facilities where allergenic extract prescription sets are prepared must have and maintain written or electronic documentation to include, but not limited to, the following:

a. SOPs describing all aspects of the compounding process

b. Personnel training records, competency assessments and qualification records including corrective actions for any failures

c. Certification reports of the PEC, if used including corrective actions for any failures

d. Temperature logs for the refrigerator(s)

e. Compounding records for any individual allergenic extract prescription sets

f. Information related to complaints and adverse events

g. Cleaning logs

h. Investigations and corrective actions

2. Compounding records must include at least the following information:

a. Name, concentration, volume, vendor or manufacturer, lot number and expiration date for each component

b. Date and time of preparation of allergenic extract

c. Assigned internal identification number

d. A method to identify of all individuals involved in the compounding process and verifying the final CSP

e. Total quantity compounded

f. Assigned BUD and storage requirements

g. Results of QC procedures (eg: visual inspection, second verification of quantities)

As plans and changes in the practice are made, it is important to keep in mind these pending revisions to the Compounding Pharmacy USP standards.

Allergy practices currently have a reprieve with the delay of the implementation of these updated rules. But with no date indicated as to when these rules will be put into effect with further review, allergy practices may be hit with these onerous rules at any time. Pay attention to notification of the rule changes.

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

Latest posts by Barbara Cobuzzi (see all)

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

October 30, 2019

We’re Gathering Stories about Our Members

At HEALTHCON this year, we listened to several members tell us their stories on camera. Some of the stories focused on how one certification changed their career, some focused on how being part of the AAPC family has been life changing. Each video is one minute or less, but they are powerful. And we feel they will help members be inspired to move their careers forward and achieve new success.

For that reason, we would like you to share one or more videos at your upcoming local chapter meetings and then report back on how it went. Ultimately, we want these stories to help other members have successful stories to tell. To start out, we suggest sharing the following videos:

#1 – Myra Simmons shares the story of going from homelessness to becoming the director of coding. https://www.youtube.com/watch?v=MN0UEpAtwqQ

#2 – For Linda Martien, the Certified Professional Medical Auditor (CPMA) certification has been life changing. She feels the industry is moving in a direction where it will need more and more auditors. https://www.youtube.com/watch?v=x-afZMh6Si4

Thanks for supporting all of our members. If you have your own stories to share, please send them to us at localchapters@aapc.com.

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam

October 28, 2019

Pennsylvania’s Act 112 to Become Effective Soon

Pennsylvania’s Act 112 to Become Effective Soon The “Patient Test Result Information Act”, or Pennsylvania Act 112 of 2018, will take full effect on December 23, 2019. The Act was originally scheduled to begin in December 2018, but the imposition of citations and fines was delayed for one year. During that time, many hospitals and radiology practices have implemented systems designed to help them comply with this law.

To review, this act provides that the patient must be directly notified within 20 days when a diagnostic imaging exam is performed that identifies a “significant abnormality” may exist. The law defines a significant abnormality as one that “would cause a reasonably prudent person to seek additional or follow-up medical care within three months”. It is important to note that this notice to the patient is in addition to the normal reporting of results to the ordering physician. A full detailed explanation of the rules to comply with this Pennsylvania state law is available in our December 2018 article.

A group of radiologists from the Hospital of the University of Pennsylvania and Pennsylvania Hospital published a case study titled “Ensuring Patient Follow-up of Significant Abnormalities Under Pennsylvania Act 112” in the September 28, 2019 edition of the Journal of the American College of Radiology. They describe in detail a variety of methods used by their colleagues in various hospitals to capture the information needed to trigger notification under the Act, summarized as follows:

Triggering event	Action taken
Hard stop; Radiologists are required to indicate within the dictation software whether a patient notification is needed	A daily structured query language report generates a list of patients for whom notification letters are needed.
	A sentence is automatically inserted at the bottom of the report from which an automated patient letter is generated.
Voluntary; Radiologists insert standardized language to flag patients who should be notified. There is no system prompt.	A natural language processing algorithm is employed to search for signed reports with key words such as “recommend” or “follow-up”.
An existing provider notification system was modified whereby reading room coordinators communicate critical and significant results for all patients designated by radiologists in the dictation software and EHR	The coordinator fills in the required patient and examination information into a patient notification letter template designed to comply with Act 112.

Some hospitals include the reporting of non-radiologist readers in their systems even though there has been no clear guidance from the state Department of Health as to which diagnostic services outside of radiology are covered under Act 112. The act specifies that the requirement to notify the patient does not apply to:

Routine obstetrical ultrasound exams
Plain x-rays
Emergency Department imaging services
Inpatient imaging services

Most practices have adopted an “embargo period” of 3 to 10 days after the report is signed before sending out the patient notice, in order to give ordering providers time to review and discuss the results directly with patients, according to the case study.

The case study authors opine that, “Pennsylvania Act 112 represents a paradigm shift in communication of abnormal diagnostic imaging findings directly to patients.” The need for such a paradigm shift was highlighted in our review of the lessons learned from the $10 million award in a medical malpractice lawsuit that might not have occurred had this law been in effect in 2015. Our blog readers will know that we have described such a paradigm shift in several articles^[1] about our own system that uses clinical analytics to identify incidental findings recommended for follow-up, notifies the patient about the situation, and then tracks their compliance with the recommendation. That same system was modified at the request of our Pennsylvania clients to comply with the Act 112 requirements.

Subscribe to this blog for the latest information that will help you maintain compliance with state and national regulations affecting your radiology practice.

[1] Healthcare Administrative Partners articles on Clinical Analytics:

Clinical Analytics for Incidental Findings Radiology Follow-up

New Study Supports the Value of IVC Filter Tracking Systems

Beyond Debate – Incidentalomas and the Need for Radiology Practice Proactivity

Closing the Loop – What Radiologists Should Know About Software

Recent Articles

What Radiologists Need to Know About ICD-10 Changes for 2020

“Closing the Loop”: What Radiologists Should Know About Software

Keeping Your Practice Independent – Build on Existing Relationships

Follow HAP on LinkedIn

Follow HAP on Twitter
Like HAP on Facebook

CPC Exam Questions & Answer Keys at http://curemydisorder.com/links/cpc-exam