Health Information Management

Who can assign E/M level coding?

APCs Insider, April 17, 2003

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April 18, 2003
Vol. 4, No. 15


Tubby Tumor

How much did the largest intact tumor ever removed weigh?

The answer will appear in next week's APC Weekly Monitor, or be one of the first five to e-mail the correct answer and win a free "2003 Coding Coach Play Book"!

Death will occur about 10 days without sleep, starvation takes weeks.

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We've got terrific resources for your APC coding team. Check out our two APC newsletters.

"Briefings on APCs" is a monthly newsletter devoted entirely to managing under APCs, including tips, charts, and advice from the experts.

"APC Answer Letter" is a question and answer publication - readers supply the questions, our experts supply the answers. Click on the links to find out more.


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Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Cheryl D'Amato,
director health information management
HSS, Inc.

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,

Julia R. Palmer
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System





Cardiac catheterization documentation tips

(Tired of struggling with CMS changes? Join the Provider Roundtable and speak out! See below)

For coders to assign cardiac catheterization codes accurately, medical record documentation provided to the coders must contain the answers to the following six questions, says Lolita Jones, RHIA, CCS, of Lolita M. Jones Consulting Services, Fort Washington, MD:

  • Does the patient have a congenital cardiac anomaly?
  • What side or sides of the heart was catheterized?
  • If left heart catheterization, what method was used to access the left side of the heart?
  • Was angiography performed? If yes, on which site or sites?
  • Was selective visualization/opacification of bypass graft or grafts performed? If yes, on which site or sites?
  • Which additional code or codes should be assigned to classify the imaging supervision, interpretation and report for the injection procedures(s) performed during the cardiac catheterization?

For more helpful tips on how to correctly code outpatient cardiology procedures, check out the audio tape of HCPro's recent audio conference featuring Lolita Jones and Pam Hess, RHIA, CPC, principal at the Wellington Group LLC, Cleveland, OH.

Your APCs Weekly Monitor, is a free weekly e-zine from HCPro, publisher of Briefings on APCs, the monthly newsletter devoted entirely to managing under APCs, and the newsletter, APC Answer Letter, with answers to readers' questions about coding for APCs.

The Monitor is a complimentary companion publication, with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the Monitor, post it on our Web site at Each week, our team of experts answers questions that will appeal to the majority of readers. The elected questions and their corresponding answers are delivered to your inbox every Friday.

TODAY'S TOPICS: Who can do E/M level coding?

Question: Does an RN have to be on the premises in order to charge an E/M level or can a physician with an LPN be permitted?

Answer: If the service is medically necessary and provided by or under the supervision of a licensed practitioner according to hospital bylaws, licensing, and accreditation requirements, you may bill for the service.

Keith Siddel, Cheryl D'Amato, Julie Downey, Jeannie Gourgeot, and Julia Palmer contributed to this week's answer.

ASK THE EXPERT: Is it appropriate to code a diagnosis from the anesthesiologist's history and physical if it doesn't conflict with the primary physician's diagnosis?

PAY PER VIEW: Outpatient outlier review is inevitable

Outpatient billing department staffs probably heaved a sigh of relief earlier this year when CMS focused its outlier payment investigation on inpatient billing.

But they shouldn't get too comfortable given that the Office of the Inspector General (OIG) has already begun investigating hospitals under OPPS for outlier overpayments.

To read more, the cost is $10. Briefings on APCs subscribers have free access via their online subscriptions.

Coding and Compliance Feature Article of the Month:
Observation miscoding can cost you

Speak out to CMS

Do you have concerns about OPPS and APCs that you would like to share with CMS?

Here is your chance!

Participate in the Provider Roundtable sponsored by HCPro Inc., Nimitt Consulting Inc., and 3M Health Information. The roundtable panel will consist of 15 health professionals representing different hospital departments that deal with OPPS and APC changes every day.

Jugna Shah, MPH, of Nimitt Consulting Inc., the group's facilitator, will work with members to document the groups' comments and questions regarding the 2004 proposed rule, provide an opportunity for reviewing the document, and then submit it on behalf of the group to CMS as part of its request for comments process.

Join your health care professional peers in presenting a united voice to CMS.

To apply,e-mail Jugna Shah and request an application. Deadline for submitting applications is May 15, 2003.

Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.


New Coding Lunch and Learn 2003 CDs are here!

Gather your colleagues for a brown bag lunch and listen to the easy-to-understand CODING LUNCH AND LEARN 2003: THE 5W's OF INPATIENT DOCUMENTATION. Learn the "who," "what," "when," "why," and "where" keys to improve documentation. You'll even earn valuable continuing education credits while you Lunch and Learn.

For more information, CLICK HERE or call our Customer Service Team at 800-650-6787. Please mention source code EZ0727A when you call.

Why are breast procedure and mammography coding and documentation so important?

Are you aware of recent coding and modifier changes for breast procedure coding? It's critical that it is done accurately, in a timely manner, and in compliance with government standards to avoid false claims. It's important to the fiscal well-being of your facility and to ensure that patients receive appropriate results of their procedures.

Learn what you need to know during a 90-minute live audioconference, "Strategies for Accurate Breast Procedure and Mammography Coding" on Tuesday, April 29, beginning at 1 p.m. Eastern. You need a solid understanding to be in compliance.

For more information or to register, CLICK HERE or call our customer service department at 800-650-6787. Be sure to mention source code EZ9087A.

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