Volume 3, Issue 4 April 2005
Meet the Staff The Security Rule
The Office of Corporate Compliance is pleased to Perhaps you’ve heard recently about patient
welcome Amy Beverley to the team. Amy will information that has been inadvertently posted
fill the position of Compliance Analyst II. on the web, or an email with patient information
being sent to the wrong party. The HIPAA
“I have worked in the
Security rule is intended to provide guidelines to
medical field for 12 years
among other things, minimize the risk of this
and 6 of that as a CPC. I
happening. We have already begun taking the
recently transferred here
appropriate steps here at MU health care. You
from Tulsa, OK, where I was
will notice, we have already updated the Code of
the Coding and Auditing
Conduct for 2005 to include information about
supervisor with the
our security practices. Code of Conduct training
University of Oklahoma. I Amy Beverley
is mandatory and should be completed prior to
have worked in all aspects of the primary care your annual performance evaluation. Annual
office from the medical records department performance evaluations are due by June 30th.
through the coding and auditing department. Much like the HIPAA Privacy rule, the HIPAA
This experience has given me the background to Security rule addresses the protection of
understand the workings of the clinical setting as individually identifiable health information, also
well as the administrative side. I am looking known as protected health information or PHI.
forward to this new and exciting adventure”. ¤
The scope of the Security Rule, however, is
limited to only the PHI created, received,
maintained or transmitted electronically by or on
behalf of a covered entity.
I5 SIDE THIS ISSUE
On April 20, 2005 we are required, as a covered
2 Billing for Smoking Cessation entity, to be in compliance with security
standards set forth in the Security Rule. These
2 National Provider Identifier standards are:
1) To ensure the confidentiality, integrity, and
3 Condition Code 44 availability of all electronic protected health
information (EPHI) we create, receive, maintain
4 Cochlear Implant Devices or transmit.
5 Director’s Column
2) Protect against any reasonably anticipated
threats or hazards to the security or integrity of
6 Announcements and Rescission of Transmittal
3) Protect against any reasonably anticipated uses
or disclosures of EPHI that are not permitted or
continued on page 2
Compliance Corner 1
4) Ensure compliance with the Security regulations by our workforce.
A team of individuals from various areas of our health care system began meeting as early as
December 2003 to begin laying out our plan for compliance under the Security Rule. The team
continues to work toward compliance in the areas of administrative, technical, and physical
safeguards under the direction of Mikel Lynch, Director of Corporate Compliance. For more
information on the Security Rule visit http://www.cms.hhs.gov/hipaa/hipaa2/default.asp. To
complete your annual Code of Conduct training on-line visit the Learning Center on Center for
Education and Development’s website at http://web.hsc.missouri.edu/ecs/. ¤
New Billing Opportunity for Smoking Cessation Counseling
The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is
adequate to conclude that smoking and tobacco use cessation counseling, based on the current U.S.
Public Health Service (PHS) Guideline, is reasonable and necessary for a patient with a disease or
an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco
use, or who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as
based on FDA-approved information. Patients must be competent and alert at the time that
services are provided. Minimal counseling is already covered at each evaluation and management
(E&M) visit. Beyond that, Medicare will cover 2 cessation attempts per year. Each attempt may
include a maximum of four intermediate or intensive sessions, with the total annual benefit
covering up to 8 sessions in a 12 month period. The practitioner and patient have flexibility to
choose between intermediate or intensive cessation strategies for each attempt. CMS will issue
two levels of service. You can temporarily use 99199 until the agency issues complete
Intermediate and intensive smoking cessation counseling services will be covered for outpatient
and hospitalized beneficiaries who are smokers and who qualify as above, as long as those services
are furnished by qualified physicians and other Medicare-recognized practitioners.
Inpatient hospital stays with the principal diagnosis of 305.1, Tobacco Use Disorder, are not
reasonable and necessary for the effective delivery of tobacco cessation counseling services.
Therefore, we will not cover tobacco cessation services if tobacco cessation is the primary reason
for the patient’s hospital stay.¤
New National Provider Identifier
Darlene Ornburn, BES, MBA, CPC, CCP
The National Provider Identifier (NPI) enrollment form CMS-10114 is in the final clearance process
and should be released in the next few days according to Allen Gillespie, a health insurance
specialist at Centers for Medicare and Medicaid Services (CMS). Mr. Gillespie, says “There is no
need to rush to get these numbers.”
continued on page 3
Compliance Corner 2
You may want to wait for a couple of months to apply for the new NPI number which will be
required under the HIPAA rules. The NPI, for all payers, private and public, will eventually
replace the current Unique Physician Identification Number (UPIN). The final application date is
May 23, 2007.
According to Part B News article, ‘If you are a physician who works for a professional
corporation, both you and company will have to apply for a NPI. The final date upon which you
must have your application in is May 23, 2007.’
The CMS-10114 form will be released in the next few days from the vendors: Fox Systems,
Scottsdale, AZ and Noridian, Fargo, ND. There will be ‘no charge’ for the NPI application
Condition Code 44 to Change Patient Status
Compliance Monitor, April 6, 2005, Vol. 8, No. 27
Facilities can change a patient's status through the use of condition code 44 (inpatient admission
changed to outpatient), effective April 1, 2004. This is for use on outpatient claims only, when the
physician ordered inpatient services, but upon internal utilization review (performed before the
claim was originally submitted), the hospital determined that the services did not meet its
Transmittal 299 describes how a hospital may change a patient's status from inpatient to
For cases in which a hospital utilization review committee determines that an inpatient
admission does not meet the hospital's inpatient criteria, the hospital may change the
beneficiary's status from inpatient to outpatient and submit an outpatient claim (13x, 85x) for
medically necessary Medicare Part B services that were furnished to the beneficiary, provided all
of the following four conditions are met:
1. The change in patient status from inpatient to outpatient is made prior to discharge or release,
while the beneficiary is still a patient of the hospital;
2. The hospital has not submitted a claim to Medicare for the inpatient admission;
3. A physician concurs with the utilization review committee's decision; and
4. The physician's concurrence with the utilization review committee's decision is documented in
the patient's medical record.
When the hospital determines that it may submit an outpatient claim according to the conditions
described above, treat the entire episode of care as though the inpatient admission never
occurred. Bill it as an outpatient episode of care.
Note: Information by Valerie Rinkle, MPA, revenue cycle director for Asante Health System in
Medford, OR. To read transmittal 299 go to
Compliance Corner 3
Expanded Coverage for Cochlear Implant Devices
The Centers for Medicare & Medicaid Services (CMS) announced that it will expand coverage of
cochlear implant devices to help treat severe hearing loss and will cover an additional oral drug to
treat chemo-therapy induced vomiting.
CMS is expanding current coverage for cochlear implants, which are used to treat bilateral pre-or-
post linguistic, sensorineural, moderate to profound severe hearing loss. Previously, Medicare
covered cochlear implants for beneficiaries with open-set sentence recognition test scores of 30
percent correct or worse.
Under today’s decision, Medicare will cover cochlear implants in beneficiaries who have test scores
of 40 percent or less correct, and will cover cochlear implants in beneficiaries who have open-set
sentence recognition test scores over 40 percent up to 60 percent if they are participating in a clinical
trial of cochlear implantation that meets the requirements outlined in the national coverage decision.
“This decision provides a way to better quality of life for many beneficiaries who did not previously
qualify for Medicare coverage of a cochlear implant, and it will help us learn whether even more can
benefit significantly,” said CMS Administrator Mark McClellan, MD, PhD.
CMS also is covering the addition of aprepitant (Emend™) to the existing combination of two other
drugs used for the prevention of nausea and vomiting when patients receive any of the specific
These treatments, known as highly emetogenic chemotherapy, have been identified by cancer experts
as causing severe symptoms in most patients who receive them. The new three-drug combination
consists of aprepitant, dexamethasone (a corticosteroid) and a 5HT3 antagonist, and is administered
immediately before chemotherapy, with additional doses given afterwards. The addition of
aprepitant will improve symptoms for those patients who do not have complete response with other
“This is a significant step in our ongoing efforts to provide the best cancer care for our beneficiaries,”
These final coverage decisions are available for review at the CMS coverage website
To view this press release:
Unbelievable Edits Rescinded
Lisa Oswald, BS, CCP
Last month we reported that n July 5, 2005, Centers for Medicare and Medicaid Services (CMS) will
begin automatically denying claims for any service(s) that exceeds a specified number of service units
per day and/or are of a type of service that could not have actually been performed according to
Transmittal 105, CR2987 . This transmittal has been rescinded. We have no other details to report at
Compliance Corner 4
Coders/Billers Get Educated
Dr. Ketan Bulsara, Department of Surgery- Neurosurgery was our honored speaker at our April
7th Coder/Biller meeting. He provided an informative presentation regarding aneurysms.
Sherry Williams, CPC, Certified Reimbursement Assistant, provided coding questions that
incorporated the topic. The following were questions and answer presented:
1. What is the ICD-9 code(s) for a complex subarachnoid aneurysm with no loss of consciousness
caused by a blow to the head from an accidental fall from a ladder? 852.01, E881.0
2. What is the CPT code for a craniotomy of an intracranial, complex, dural arteriovenous
3. What is the CPT code for an intracranial approach of a 14 mm temporal artery aneurysm? 61700
4. What is the ICD-9 code for an aneurysm of the meninges? 437.3
5. What is the CPT code for an intracranial approach of a 16 mm internal carotid artery aneurysm?
Do you have a physician that loves to share information about the services he/she provides? Do
you have excellent communication skills? If you or someone from your department would be
interested in presenting information at one of our future Coder/Biller meetings, please contact
the Office of Corporate Compliance at 882-3293 to schedule a date and time. ¤
Medlearn Matters - Another resource for information
The Centers for Medicare and Medicaid Services (CMS) recognizes that the Medicare provider
communities have been hampered by the number, frequency and complexity of Medicare changes.
CMS also received feedback from Medicare providers that it is difficult to stay up-to-date with all
the changes, rules and regulations. Therefore, in February 2004, to bridge that gap, CMS and your
Medicare Learning Network introduced Medlearn Matters- a new educational resource for
Medicare Providers, designed to inform you of important changes to the Medicare system by
actual clinicians and billing experts.
For those interested in receiving news from CMS, Medlearn Matters offers an electronic mailing
list service. There is a wide variety of available mailing lists from Ambulance Services to Skilled
Nursing Facilities (SNF). The service is optional, you can select the areas of interest and you can
subscribe or unsubscribe from any of CMS's mailing lists at any time. ¤
Compliance Corner 5
$613 Million Medicare Overpayment
for Incorrectly Coded and Documented Consultations
OIG Report Findings
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently
released a report (OEI-09-02-00030) that included their complete study of data from 2001 which
revealed that Medicare allowed a net overpayment of approximately $613 million for incorrectly
The errors associated with the incorrectly coded consultations included services that were
determined as not actually consultations, or incorrect types and billed at incorrect levels. The OIG’s
review also indicated that many of the services were not documented adequately.
After completion of their report, the OIG recommended that the Centers for Medicare and Medicaid
Services (CMS) educate physicians and other health care practitioners regarding the criteria necessary
and proper billing for all types and levels of consultations with an emphasis on the highest billing
levels and follow-up inpatient consultations.
This Social Security Act (Sections 1848(a)(1)) established the physician fee schedule as the basis for
Medicare reimbursement for all physician services, including consultations, beginning in January
1992. In addition, the act also required the Secretary of the Department of Health and Human
Services to develop a uniform procedure coding system for all physician services, and specifically call
for “an appropriate coding structure for…consultations.”
In adopting the physician fee schedule in 1992, the Code of Federal Regulations (CFR, Title 42, Part
411, Section 411.351) and the Medicare Carriers Manual (Section 2020C) allow for Medicare
reimbursement for consultations if the following conditions are met (not applicable to confirmatory
The service is provided by a physician whose opinion/advice is requested by another physician or
other appropriate source regarding evaluation and/or management of a specific medical problem;
The written or verbal request and need for the consultation must be documented in the patient’s
medical record; and
After the consultation is provided, the consultant prepares a written report of his/her findings, which is
provided to the referring physician.
CMS further clarified in September 2001 in an update in the Medicare Carriers Manual, that
physician assistants, nurse practitioners and certified nurse-midwives may request and perform
consultations if the services are within their scope of practice, as defined by State Law.
What is a consultation? The Current Procedural Terminology (CPT) defines a consultation as “a type
of service provided by a physician whose opinion or advice regarding the evaluation and/or
management of a specific problem is requested by another physician or other appropriate source.”
A consultation involves a specific request for help with a particular diagnosis or course of treatment,
while an office or inpatient visit involves ongoing care of the patient.
Compliance Corner 6
Please see the special edition of Medlearn Matters for detailed information regarding categories,
levels and types of consultations, as well as the documentation requirements necessary for each.
This special edition of Medlearn Matters was published to facilitate the OIG’s recommended
education regarding consultations.
June 14, 2005
Evaluation and Management Registration 8:00 a.m.
1510 Jefferson St.
Documentation Seminar 8:30 a.m. ~ 12:00 p.m.
Jefferson City, MO
June 14, 2005
Evaluation and Management Registration 12:30 p.m.
1510 Jefferson St.
Documentation Seminar 1:00 p.m. ~ 4:30 p.m.
Jefferson City, MO
Compliance Corner 7
Mikel Lynch, BS, MPA
Privacy and Security: What’s the Difference?
On the 20th of April, the newest HIPAA Rule will become operational. This is the requirement that
we provide “reasonable” security for our patient information that exists on our electronic systems.
You will remember that two years ago, the Privacy Rule became operational. That rule required
that we provide protection form inappropriate access to patient records, while providing greater
freedom to access records by the patient.
So what is the difference?
The analogy I often use is to imagine that you work in Medical Records. We would have rules
about who is allowed access to this facility, what records are kept here, who transports them, how
we account for the location of the records, how we make copies of records, and who is allowed to
see these records. These would be the privacy rules.
Now, what if at 5 o’clock we all left work and didn’t lock the record room door behind us? What
use are all of our rules? That is where Security comes in. Security is the enforcement mechanisms
that help us ensure that everyone follows the privacy rules. In this case, we could install an
automatic door closer with an automatic combination lock so that only authorized staff would
have access, even if we failed to lock the door.
Also, we can tell our staff that they must log off of a workstation if they will be away more than 5
minutes, but if they have an automatic screensaver with password protection, we have some
assurance that even if the employee forgets, the patient information will be “reasonably”
We can also tell our staff not to open suspicious e-mail because it may contain a dangerous virus,
but our e-mail administrator uses tools to scan for all such viruses before your mail arrives, and
deletes the attachments before you have a chance to make a mistake.
Sounds like the staff member doesn’t really have to worry, if all of this is done for them…right?
There are still a number of mistakes a staff member can make. For example, you might be tempted
to share your password with a new employee so that they can become productive from the first
day, before they have their own password. This can lead to accusations that YOU accessed patient
information for which you were not authorized. You can copy patient information on a diskette,
CD or memory stick and accidentally lose it. You might fax patient information to a wrong
To summarize, we will be trying to implement as many tools as possible to ensure that careless
mistakes are minimized, but you will continue to be the most important element in preventing
accidental disclosure of patient information. The 2005 Code of Conduct will provide more
information on this subject, and we will continue to keep you alerted to other issues as we
progress past April 20th….¤
Compliance Corner 8
ANNOUNCEMENTS AND UPCOMING EVENTS
NATIONAL HEALTH INFORMATION AND SAFETY WEEK
APRIL 10 – 16, 2005
Office of Corporate Compliance is hosting an informational booth dedicated to HIPAA Privacy and
Security issues. Learn where to find information in our own policies. Find out what AHIMA
considers to be the top ten Privacy and Security Challenges in the electronic health record (EHR)
transition. Pick up a quick reference guide that answers some top privacy & security questions about
processes. We’ve got some fun activities planned as well. Stop by and see us at one of these locations
between 10 a.m. and 2 p.m.
Monday, 4/11/05 – UHC Main Lobby
Tuesday, 4/12/05 – CRH Cafeteria
Wednesday, 4/13/05 – Ellis Cafeteria
Thursday, 4/14/05 – MRC Cafeteria Hallway¤
Thursday, May 5, 2005
2-3 p.m. UPMB 3003
Review of consultations (types, documentation requirements, levels, etc.) and roundtable discussion
regarding other important billing and coding issues.
AAPC SHOW ME CHAPTER MEETING DATES 2005
April 14, 2005 - Room QD228 - Time 8:30 - 11:00 am
Dr. Pierantonio Russo will speak on Congenital Heart Defects with coding scenarios to follow.
May 12, 2005 - Room QD228 - Time 8:30 - 11:00 am
Dr. Sara Crowder, Gynecologist Oncologist will speak on GYN Cancer , procedures, staging and anatomy. Coding
scenarios will follow.
June 9, 2005 - Room QD228 - Time 8:30 - 11:00 am
August 11, 2005 - Room QD228 - Time 8:30 - 11:00 am
September 16, 2005 - Lenoir Community Center 9:00 am – 4:00 pm
Speaker will be Sean Weiss from CMC Consulting Group in Atlanta, GA
October 13, 2005 - Room QD228 - Time 8:30 - 11:00 am
November 10, 2005 - Room UPMB 3003 - Time 8:30 am - 11:00 am
December 8, 2005 - Room QD228 - Time 8:30 am - 11:00 am
Compliance Corner 9
CPC Test Reviews will be held on:
Saturday August 6, 2005
Saturday, November 5, 2005
These test reviews are from 8:00 am to 4:00 pm and will be held at
the QuarterDeck Building in Columbia, Mo Room QD237.
There is no break for lunch, so the instructor encourages attendees
to bring snacks or lunch.
There is a charge of 39.00 per person and attendee will receive 6
For questions or concerns please contact Linda Martien at
AAP C E X A M D A T E S 2005 TIMES ARE FROM 7:30 AM UNTIL 2 PM
May 14, 2005 QuarterDeck Building QD237
August 13, 2005 QuarterDeck Building QD237
November 12, 2005 QuarterDeck Building QD237
Compliance Corner 10