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Archive for October, 2009

Is Your Referring Physician Enrolled in PECOS?

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

Beginning on October 5th, if the name of an ordering/referring provider appears on a Medicare claim, this provider will be compared against the Provider Enrollment Chain and Ownership System (PECOS). Between this date and January 3, 2010, if the referring provider is not found in the PECOS system, informational claim adjustment reason codes and remittance advice remark codes will appear on the explanation of Medicare benefits stating that the ordering/preferring provider identifier is invalid.

Beginning on January 4th, 2010, any claims that include invalid referring physician information will be denied. In addition, any provider who does not appear in the PECOS system with up-to-date information runs the risk of being excluded from the Medicare program for a period of one year.

It is imperative that Medicare remittance advice be watched very closely during this Phase 1 period. For providers who rely on patient referrals for the bulk of their business, such as specialists and laboratories, any warnings received should be shared with the referring providers in question to bring this situation to their immediate attention, as continued non-compliance with this enrollment rule by referring or ordering providers could lead to your claims being denied.

Fortunately, the PECOS system has simplified what can be a laborious enrollment process. Simply go here to begin the process and follow the step-by-step on-screen instructions. After completing this process,  remember to sign and return the two-page certification form within seven days of you PECOS submission. Your information in the PECOS system will not be completed without this step. If you have previously registered with the PECOS system, go here to login to the system and update your information. If you experience technical difficulties during the process, CMS offers help desk support from 7 AM to 7 PM Eastern Time Monday thru Friday either by calling 1-866-484-8049 or by e-mailing .

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October 30th, 2009 | 2 Comments »

Checking In From The Road to ICD-10

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, J. Paul Spencer, CPC CPC-H

I bid you all Friday greetings from suburban Atlanta.

I’ll share the reasons for this week’s appearance being from Georgia momentarily, but being on the literal road during what will be my last vacation stop of the year reminds me of another figurative road I currently find myself upon as a coder; the road to the implementation of ICD-10 as the reporting standard for diagnosis and symptomology reporting.

In a little under four years, ICD-9 will be a thing of the past. Replacing it will be a code set containing over 100,000 codes. While at first this seems daunting and deflating, I console myself with the knowledge that ICD-10 will lead to an advanced degree of specificity in diagnosis and treatment of patient conditions. It is hoped that one outcropping of this will be a general increase in favorable patient outcomes.

It is important for me to point out that I was one of the coders in the minority who felt that it would have made more sense to wait for ICD-11, which is set to be released by the World Health Organization (WHO) in 2014, roughly three months after American adoption of ICD-10. Unfortunately, The American Hospital Association (AHA) and the American Health Information Management Association (AHIMA) felt that it was more important to ram ICD-10 forward quickly and at all costs rather than be on the same page diagnostically with the rest of the medicinally civilized world. The official reason given in the Final Rule was that it would take 5 years to come up with a clinical modification to ICD-11. This is belied by the fact that WHO is building a clinical modification to ICD-11 as part of the initial release. In ten years time, the American health care reporting infrastructure will find itself exactly where it finds itself now; utilizing an outdated coding system that is out of step with the rest of the world. Given the lengthy debate that just recently ended with ICD-10, it is extremely possible that I shall be dead before ICD-11 become a reality in the United States. With an outdated reporting and diagnostic structure, I may not be alone.

Let me try to end this on a high note. So you may be asking what brought me to Georgia. I have an old friend who lives just north of Atlanta who is recording his second album, and I have been recruited to supply lead vocals on four tracks. I’m about to do the last track once this entry is finished. It may come as a surprise to many of you that my incessant bellowing takes on many forms. I now transition from the semi-professional scribblings you are used to here to the musical warblings of my hobby life. Enjoy your weekend, wherever you are.

October 23rd, 2009 | No Comments »

The Riddle Of “Meaningful Use” Soon To Be Defined

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, J. Paul Spencer, CPC CPC-H

Mankind, being the one member of the animal kingdom capable of rational thought, has left behind many written documents of the quest for answers and definitions to questions relating to its existence. Despite centuries of thought, many questions still remain, such as:

  • Where did that sock disappear to from the laundry?
  • Where did they get the cream for the coconut cream pies on “Gilligan’s Island”?
  • If the afterlife is the perfect place, why do so many people dislike harp music?

This is my short list. I would imagine the questions on your list vary.

One question in the realm of medical billing and documentation that deserves an answer will be coming soon. As we learned after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act provision of the American Recovery and Reinvestment Act of 2009, Medicare will begin to pay incentives to physicians who begin “meaningful use” of an electronic medical record.

The term “meaningful use”, to date, has not been defined, but Dr. David Blumenthal, the National Coordinator for Health Information Technology (HIT), stated in an online open letter posted here on October 1st that the Centers for Medicare and Medicaid Services (CMS) are expected to give a draft definition of this term by the end of the claendar year. This will be followed by a public comment period that is expected to help further define this term before presentation of a final rule.

Speculation has been that this term will include current reporting programs such as PQRI and E-Prescribing, along with clear functionality, security and interoperability with other electronic medical records systems. As we get closer to the implementation of the bonus program in 2011, a clear picture will begin to emerge as to what will be needed to qualify for the HIT bonus.

There will be a government-backed certification (known as a CCHIT) for EMR systems that meet these still-preliminary standards. I remain puzzled by entities who are purchasing EMR programs prior to certification without knowing whether these will be able to meet standards. I would imagine that for some of these purchasers, the answers on meaningful use and certification will not be the ones for which they’d hoped.

So as you ponder a legion of people with only one sock, the mystery milk-producing animals of Gilligan’s Island and the idea of other more mainstream musical instruments in the afterlife, know that at least one of your questions will soon have an answer.

October 16th, 2009 | 3 Comments »

A Signature Makes it Count

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, J. Paul Spencer, CPC CPC-H

Next to me on my desk is my wallet (I see you coming up behind me – BACK OFF!). I’m reaching in and randomly pulling out four items. First, there’s my driver’s license (the fact that I have one that has yet to be revoked will probably come as a shock to those who have actually seen me drive). On the bottom left hand corner of my license is my signature, making it official.

Next comes my bank-issued debit card. Turning it over, I again note my signature, allowing me to complete purchases out in the Great Beyond. Next comes my supermarket savers club card (the one that tracks my continuing purchase of junk food that gave me the two chins I’m sporting on the aforementioned driver’s license). I turn it over, and even this card has a signature block, which is used to verify signature in the event I feel like writing a check at the supermarket (I’m a man; I never do). Finally, I have my major credit card, complete with self-selected hockey theme on the front and yes, my signature on the back, making it official. 

If I am out about town and I want to complete a monetary transaction without cash, it becomes imperative that my signature be on all of the items above. Now take this idea for a moment and expand it to a handwritten medical record.

When a medical claim is submitted to an insurance provider, what a physician is telling the payer is that the form he or she has submitted for reimbursement is a numerical representation of a medical record in the physician’s possession that justifies the billing. However, if that medical record lacks the physician’s signature, what is being submitted for payment is invalid.

While the first and foremost responsibility of any physician is the care and well-being of his or her patient population, there must be a constant awareness that every patient who presents for care represents a compensation opportunity. The easiest action to take to ensure that any one opportunity doesn’t slip through the physician’s fingers is the placing of a signature on every medical record.    

Beginning in 2011, Medicare will begin to pay nominal bonuses for the meaningful implementation of an electronic medical record. While that time is virtually right around the corner, the reality is that there are many physicians who currently utilize a handwritten medical record for their patients. Without a physician signature on those medical records, it is as if the services being documented never existed. When it comes to claims appeals, lack of signature on a medical record gives your claims appeal the life expectancy of a deer wearing a bell around its neck during hunting season.

Signing a handwritten medical record should be viewed just like a check or a credit card; without a signature, a transaction won’t occur. To put it in colonial terms, if I don’t have a John Hancock, I can’t buy a 12-pack of Samuel Adams (why did an idea for the weekend just pop into my head?). Similarly, if a doctor doesn’t have a John Hancock, the Benjamin Franklins won’t be showing up.

October 9th, 2009 | No Comments »

So Much News, So Little Time

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, J. Paul Spencer, CPC CPC-H

Anyone who has known me for any significant amount of time knows that when the calendar moves to October, it officially becomes “Spencer Time”. Not only does tonight mark the beginning of hockey season (beware of flying pucks!), but (much like the 19th Century Russian existentialist literature that I so enjoy) the sky turns grey, the cold air in my lungs awakens me from my overheated summer doldrums and the leaves around me begin to get the dry, multicolored, crackling smell of cyclical death. I wouldn’t trade being alive in the season of Autumn for anything in the world.

Yet the leaves are not alone in this season of change. All indicators point to strange times ahead in the medical reimbursement field. I thought I’d take a quick moment to point out some important bits of news to keep in mind as we move from Summer to Spencer Time.

ICD-9 Coding Updates - The 2010 ICD-9 codes are effective for all services dated today and forward. The majority of the changes in this year’s edition of the quickly-expiring ICD-9  (ICD-10 begins four years from today) are in the External Causes section. This is an outgrowth of the unfortunate reality of the increase in injuries to our soldiers serving in Iraq and Afghanistan. For commonly used codes, the diagnosis of gouty arthropathy (274.0) has been expanded to a 5th digit to indicate whether the condition is acute or chronic. There are a number of additions for venous emboli (453.50 thru 453.89), with language that for the first time identify the specific location of the embolism. There has also been a revision in the language of code 584.5 thur 584.9 from “acute renal failure” to ”acute kidney failure”.

Swine Flu Vaccine - With the sudden appearance of the H1N1 flu virus, it has become necessary for procedural coding to keep up with the treatment of this illness. For Medicare, code G9141 is to be used for the administration of the H1N1 vaccine and G9142 is used for the vaccine itself. For all other payers, the G codes will not be accepted, so instead use 90471 for the administration and 90663 for the vaccine.

The Red Flags Rules – The thrice-delayed FTC rules for establishing red flags for identity theft will begin to be enforced on November 1, 2009. If you have not done so already, be certain you have internal processes in place for a smooth transition to these rules. To review, every patient that presents for treatment should have hardcopy versions of a state issued ID and any insurance card. It is strongly recommended that any patient presenting for other than emergency treatment without these materials be deferred from care until such time as they can be legitimately acquired.

In related news, it is already shaping up to be an interesting month related to the many variations of the health care legislation furiously paddling their way through the paved swamp that is Washington, D.C. I advise the reader to rely heavily on trusted information sources and do their very best to cut through the layers of dogma and invective to find the truth about the future of health care in the United States.

For now, I have cold air that must be inhaled, leaves to crunch underfoot and dozens of hockey fights to which I must bear witness. All hail Spencer Time!

October 1st, 2009 | No Comments »