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									 Medicare Coverage of Sleep Apnea….…2

Bundled Codes…………………………...2
                                                            Volume 7             Issue 3   March 2009
 E/M Tips……………………..……,……...4

 In the News – False Claims .…..…,….6

 Auditing Workshop m………..….,…….7

 SON Seminar…. …………………….,,…..9

 2009 Code of Conduct LIVE……………10

 Our mission is to assist and enable the enterprise to meet its academic, research,
 and clinical missions by preventing, detecting, and correcting non-compliance with
 applicable legal, regulatory, and oversight obligations.

  It’s the Law
  HIPAA (Health Insurance Portability and Accountability Act) has been around for a while and most of us are very
  aware of the Privacy and Security Rules and how they apply to our everyday work. Like most things we become
  comfortable with, we begin to take short cuts after a while and perhaps aren’t quite as careful as we were initially.

  A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while
  allowing the flow of health information needed to provide and promote high quality health care and to protect the
  public's health and well being. (http://www.dhhs.gov/ocr/privacy/hipaa/understanding/summary/index.html). The
  Privacy Rule states we must ―make reasonable efforts to limit protected health information to the minimum
  necessary to accomplish the intended purpose of the use, disclosure, or request‖. (CFR45 § 164.502). MUHC policy
  states ―

  In the Notice of Privacy Practices, which we give to every patient upon first point of service within our health care
  system, we make a promise; to protect their patient information.

  We communicate PHI daily to any number of people via any number of mediums; telephone, e-mail, fax, and face-
  to-face conversations. Once PHI is in our possession, it is our responsibility to make sure the confidentiality of that
  information remains in tact. How can we do it?

  Here are some simple tips to follow:
              If you have PHI in your office, close your office door when you are away; better yet – lock it.
              Lock file cabinets that store PHI when you are not using them.
              Turn PHI face down on desks and at nursing stations so wandering eyes won’t ―accidentally‖ see
              Be aware of your audience. Don’t hold conversations in public areas. Whether you are on the phone
                are talking face-to-face with someone, make the effort to keep unauthorized personnel from
                overhearing your conversation.
              If you are faxing, verify the number you are faxing to is the correct number before dialing.
              Basically, treat other people’s PHI as you would like yours treated.

  Want to test your knowledge on HIPAA? Take the HIPAA on-line course at
  http://www.muhealth.org/compliance/modules.shtml. ☼

                                                                                                 COMPLIANCE CORNER        1
Medicare Coverage of Sleep Apnea
Shelli Martin, BA, CPC-EMS, CPC-H, CCP-P

Obstructive sleep apnea is a condition that is characterized by periods or temporary absence of breathing during
sleep. OSA occurs when the brain sends a signal to the muscles and the muscles make an effort to take a breath,
but they are not successful because the airway is obstructed and prevents the flow of air.

The most common symptoms of OSA are:

        Loud snoring;
        Nocturia;
        Excessive daytime sleepiness;
        Memory and concentration problems;
        Morning or night headaches;
        Heartburn or sour taste in the mouth;
        Edema; and
        Sweating or chest pain while sleeping

The American Academy of Family Physicians (AAFP) reports that obstructive sleep apnea affects up to 4 percent
of middle-aged adults. The Centers for Medicare and Medicaid (CMS) recognizes that OSA is associated with
significant morbidity and mortality. It is more prevalent as a person ages (up to 10%) as well as increased weight.

On March 3, 2009, CMS announced a new policy for Medicare coverage of sleep testing for the diagnosis of sleep
apnea. CMS Acting Administrator, Charlene Frizzera, explains that this coverage decision establishes nationally
consistent coverage and offers reassurance to Medicare beneficiaries that are diagnosed with sleep apnea they can
be referred for treatment. The decision does not apply to the use of these tests for other purposes beyond the
diagnosis of OSA.

Please see the Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N) in its
entirety at:

https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=227& ☼

Get Paid Separately for Bundled Codes
Physicians Practice Pearls, March 5, 2009 Vol. 10 No. 9

Have you ever tried to use modifier 59 (Distinct procedural service)? From its description, it might seem like a
magic bullet. You can split two procedures (bundled by the Correct Coding Initiative, or CCI) so each can be paid
separately. Sounds great.

But be careful. If you don’t properly justify its use, modifier 59 can turn poisonous, abusive, and possibly
fraudulent — not what you want.

There are two legitimate reasons to unbundle codes that the CCI considers bundled: When they are performed

                                                                                            continued on page 3

                                                                                      COMPLIANCE CORNER            2
during different encounters in the same day, and when the procedures were performed on separate anatomical

The Department of Health and Human Services’ Office of the Inspector General has targeted inappropriate
use of modifier 59 for scrutiny because some providers appear to use the modifier as a ―license to unbundle‖
without being able to justify the ―separate site‖ or ―separate encounter.‖

To use modifier 59 successfully, first understand why it exists and when to use it.

      Separate encounters — Say a physician performs a diagnostic nasal endoscopy (31231 — Nasal
       endoscopy, diagnostic, unilateral or bilateral [separate procedure]). Later that day, the patient shows
       up in the emergency room with a nose bleed. The same physician is called in and he performs a
       cautery of the nose bleed (30903 — Control nasal hemorrhage, anterior, complex [extensive cautery
       and/or packing] any method). These two codes are normally bundled together — control of bleeding is
       considered part of the endoscopy procedure — but since they were done in separate patient encounters,
       the use of modifier 59 is appropriate and the physician will be paid for both codes.

       Since 30903 is the Column II code (considered bundled into 31231), you append modifier 59 to it. You
       would code 31231 (with the diagnosis for the earlier encounter) and 30903-59, 784.7 (Epistaxis).
       Tricky part: You don’t always append modifier 59 to the second procedure performed; you append it
       to the column II code in the pair.

      Separate sites — Another reason to use modifier 59 is to notify the payer that although two codes are
       normally bundled, they describe procedures that were done on different anatomical locations.
       Performing bundled codes on different locations does not qualify them for bundling, but payers’
       software will automatically bundle the codes and only pay for the column I code. Use modifier 59 to
       notify the payer of this special circumstance.

       For example, a patient is in the operating room for a biopsy of her left breast and a partial mastectomy
       of her right breast. The surgeon is performing the partial mastectomy of the patient’s right breast since
       a prior biopsy has shown a lesion there to be malignant. A breast biopsy (19101 — Biopsy of breast;
       open, incisional) is bundled into a partial mastectomy (19302 — Mastectomy, partial [e.g.,
       lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy). In order
       to get paid for both, you might think that just putting an LT modifier on 19101 and a RT modifier on
       19302 would work, but it doesn’t. Many payers, including Medicare MACs/Carriers, don’t pay based
       on the LT and RT modifiers. In order to break the bundle, you must append modifier 59 to the column
       II code, 19101. The service, indicating separate sites in the same encounter, could be 19302, 174.9 and
       19101-59, 239.3 (the diagnoses could differ, depending on the documentation).

For consistent success with using modifier 59, think like a bundler: Consider the mindset of the CCI editors
when they created a bundle. If a different device is needed to perform the second procedure, it is likely the
editors of CCI factored that into the bundle. Simply switching devices does not make it a separate service. If
you scope two separate locations which are defined by two different codes, it is highly likely that those
creating the CCI bundle expected that would happen, so modifier 59 is not justified just because you
examined two locations; it’s implicit in the bundle.

                                                                                      continued on page 4

                                                                                      COMPLIANCE CORNER            3
Err on the side of safety when considering modifier 59, and document well. Then if you do get called out on using it,
make sure that when you take the stand in a fraud and abuse case or a refund request, you can fully defend your

Barbara J. Cobuzzi, MBA, CPC, is president of CRN Healthcare Solutions in Tinton Falls, N.J., a healthcare
consulting firm. Cobuzzi is also a senior coder and auditor for The Coding Network and a past member of the
American Academy of Professional Coders (AAPC) National Advisory Board and Executive Board. She has served
as an expert witness on both civil and criminal fraud cases, and has written for many key publications in the medical
coding and reimbursement industry. ☼

Shelli’s Coding Question
We did not have a winner in February so we are running this
question again. Challenge yourself. See if you can figure out the
correct answer!
                                                                      Shelli Martin, BA,
                                                                    CPC-EMS, CPC-H, CCP
Follow these instructions to answer the questions below:

Instructions: Go to The U.S. Department of Health and Human Services- Office of Inspector General web site, find
the Fraud Prevention and Detection, Exclusion Program, and search the Online List of Excluded Individuals/Entities


1) How many exclusion types are listed?

2) Which is the description of the type of exclusion that has the most exclusions?

First correct answers to oswaldl@health.missouri.edu wins a 2009 Pocket Pal calendar/planner. ☼

E/M Tips…
By: Leanne Rotter
Review of Systems (ROS); what is it? ROS is obtained through a series of questions asked by the provider,
searching to identify signs and symptoms that the patient has experienced or is experiencing. ROS helps to further
define the problem(s), helping the provider clarify what testing is needed, diagnosis(es) that are being assessed and
possible treatment options. But, make sure that you don’t ―double dip‖ with information from the History of Present
Illness (HPI). If that is done, your level might be higher than actual service rendered and a higher level of service
billed; ―any‖ payer could consider that practice as up coding.

                                                                                              continued on page 5

                                                                                           COMPLIANCE CORNER        4
Review of Systems as listed in American Medical Association and Centers for Medicare and Medicaid Services
Documentation Guidelines, are:

Constitutional: fever, weakness, fatigue
Eyes: infection, discharge, itching, tearing or pain, floaters, glaucoma, cataracts, blurred or double vision
ENMT: Hearing test, sensitivity to noise, ear pain, ringing, vertigo, nosebleeds, sinusitis, gums, hoarseness,
difficulty swallowing
Cardiovascular: Chest pain, palpitations, murmurs, irregular pulse, edema, coldness to extremities
Respiratory: Asthma or breathing problems, chronic cough, sputum production, wheezy or noisy respirations
Gastrointestinal: Indigestion, hematemesis, bloating, burning in esophagus, nausea and or vomiting, hemorrhoids,
bowel habits
Genitourinary: painful urination, incontinence, frequent urination, testicular pain, erectile dysfunction, last
menstrual period
Musculoskeletal: fracture, muscle cramping, joint swelling, deformity, stiffness, injury
Integumentary: Any skin disease, itching, scars, moles, sores, color, varicose veins, breast pain/lump
Neurological: Syncope, unconsciousness, seizures, memory issues, stroke, head injury
Psychiatric: Anxiety, sleep disturbance, hallucinations
Endocrine: Adrenal problems, diabetes, changes in weight/height, appetite, thirst, hair change, thyroid
Hematologic/Lymphatic: Anemia, bruising, low platelet count, transfusions, lymphadenopathy
Allergic/Immunologic: Hives, itching, sneezing, allergies to meds
“All Others Negative”: A statement stating all systems are negative is allowed after addressing the positive
findings – it is important to list any pertinent ROS prior to stating ―all others negative‖.


      Mr. Smith is a 17-year-old male referred by Dr. Barry Jones from Jefferson City. He sustained an injury to
       his right wrist in a motor vehicle accident on January 3. He states that he was originally seen at the Lake
       and had a follow up at Capital Regional Hospital. He was in a non-removable splint for approximately 10-
       14 days and since has been in a removable splint. He states that he has been out of the splint far more than
       actually in it. He has some occasional soreness in his wrist, mainly just stiffness and not a lot of pain. He
       has also had some stiffness of his index finger on the right hand since his injury. He has a history of a
       flexor tendon repair in this finger at age 12. He is not taking any pain medication for his wrist currently.
       He has had x-rays and an MRI performed. He denies any pain in his left hand. Positive for reading glasses,
       otherwise all other elements of the ROS are negative.
           1. Musculoskeletal: hand
           2. Constitutional: reading glasses
           3. “All Others Negative”
       ROS would level to “Comprehensive”.

    Patient comes in to see us after finding a relatively large mass in the right breast. She underwent
     mammogram ultrasound and there is a highly suspicious grade 5 mammogram of the right breast suggestive
     of breast cancer. Patient states that this has gradually gotten bigger over the preceding several months. She
     comes today for further recommendations and management of this mass. Occasional swelling of the legs
     and bone and joint pain, otherwise her ROS is negative.
         1. Integumentary: breast mass
         2. Musculoskeletal: swelling of legs, joint pain
         3. ROS “negative”
   ROS would level to “Detailed”. The provider does not indicate a number of ROS reviewed; therefore,
   would not be considered in the leveling.
                                                                                           continued on page 6

                                                                                      COMPLIANCE CORNER           5
        77-year-old white female fell 10 days ago and hospitalized for left arm fracture. Had a small
         laceration on her face which was sutured. No loss of feeling in the jaw near the laceration. Patient is
         feeling good today and has no other complaints.
             1. Musculoskeletal: no loss of feeling
         ROS would level to “Expanded Problem Focused”.

Of note: When the provider does not document a ROS, the level would be “Problem focused”. ☼

Kansas Cardiologist to Pay $1.3M to Settle False
Claims Act Allegations
March 04, 2009 | Chelsey Ledue, Associate Editor

WASHINGTON – A Kansas cardiologist and his practice group will pay $1.3 million to settle claims that
they submitted false claims to Medicare.

The Justice Department contends that from 2001 to 2006 Joseph P. Galichia, MD, and the Galichia Medical
Group violated the False Claims Act by submitting claims for services not provided and, in other instances,
submitting claims without proper documentation.

In May 2000, Galichia and the Galichia Medical Group agreed to pay more than $1.5 million to settle a
previous False Claims Act matter. In that case, between 1993 and 1998, Galichia allegedly billed Medicare for
a higher level of services than provided (up-coding), billed twice for the same services and billed for services
not provided.

"The Department of Justice is committed to ensuring that Medicare funds are paid out appropriately for
services actually provided to beneficiaries," said Michael F. Hertz, acting assistant attorney general for the
department’s civil division.

As part of the settlement, Galichia and the Galichia Medical Group have signed a so-called "integrity
agreement" with the Department of Health and Human Services' Office of Inspector General. The agreement
contains measures to ensure compliance with Medicare regulations and policies in the future.

"Exposing Medicare fraud is a top government priority," said Lewis Morris, chief counsel to the Inspector
General of the Department of Health and Human Services. "We will aggressively pursue both individuals and
companies seeking to enrich themselves by cheating U.S. taxpayers and the nation’s healthcare system." ☼

                                                                                       COMPLIANCE CORNER           6
                                                                                                                      Dr. Ornburn is the Administrator and
                                                                                                                      Compliance Officer for University of
                                                                                                                      Missouri Health Care. A former
                                                                                                                      PricewaterhouseCoopers LLP senior
                                                                                                                      consultant, Dr. Ornburn’s experience
                                                                                                                      affords her the knowledge to recognize
                                                                                                                      the criteria necessary to meet the
                                                                                                                      government's strict documentation
                                                                                                                      guidelines for compliance with
                                                                                                                      regulations that govern our health care

                                                                                         Darlene Ornburn, PhD, CPC,
                                                                                                CCP-P, CHC

                                                                                      Ms. Lewis is an audit analyst for the Office
                                                                                      of Corporate Compliance with University of
                                                                                      Missouri Health Care. Ms. Lewis began her
                                                                                      career in health care as an LPN in western
           1 Day Workshop $125                                                        New York. She has coded for a large
                                                                                      national radiology group and also for a multi
  $99 if you register before April 1, 2009                                            specialty group practice. She brings 30
                                                                                      years of experience in health care to this

        5 AAPC approved CEU’s                                                         workshop.

                                                                                                                                  Stephanie Lewis, CPC,
                                                                                                                                     CCP-P, ACS-EM

                         APRIL 22, 2009 8:30 A.M. – 4:30 P.M.
                HOLIDAY INN EXECUTIVE CENTER – Parliament II conference room
                         2200 I-70 Drive SW       Columbia, MO 65203 573-445-8531 1-866-538-6197
                          Register early! Contact Lisa Oswald at oswaldl@health.missouri.edu , 573-882-3293,
                                                      or complete the attached registration form.
                        We are going Green. You will receive our presentation and hand-outs electronically two days before the workshop.
                                      Workshop materials include guidelines that will assist you in auditing your practice

                          Agenda                                                                 Hands on Auditing
8:30 - 9:00      Registration and Networking
                                                                                             2 ½ hours of practical application:
                 Continental Breakfast                                                     Bring your CPT and ICD-9-CM books.

9:00 – 10:15    CPT Auditing                                               Ask yourself:
                Why Audit? How to Audit.                                        How is auditing important to my practice?
                How UMHC applies government                                                o     Know and understand your potential risk
                                                                                     Am I putting my practice at risk?
10:15 – 10:30   Break                                                                      o     Scribing
                                                                                           o     Billing for services not rendered
10:30 – 11:45   Hands-on, PRACTICAL APPLICATION                                            o     Over payments
                with group discussion
                                                                                     How am I dealing with those ―gray areas‖?
11:45 – 12:45   Lunch provided                                                             o     Medical necessity or acuity of patient’s condition
                                                                                           o     Bundling/unbundling
12:45 – 1:15    HIPAA Auditing                                                             o     Utilizing modifiers

1:15 – 1:45     Diagnosis Auditing                                                   Is my diagnosis coding supporting the service I
1:45 – 3:00     Hands-on, PRACTICAL APPLICATION                                            o     Linking to each service on a claim
                                                                                           o     Sequencing primary and secondary diagnoses
                with group discussion

3:00 – 3:15     Break (refreshments)                                                 Am I billing our non-physician practitioner’s services
                                                                                           o     Understand the difference between ―incident-to‖
3:15 – 4:30     Non-physician Practitioner Guidelines and
                                                                                                 and ―split-shared‖ services.
                Teaching Physician Guidelines with

                                                                                                                           COMPLIANCE CORNER                    7
      Compliance & Quality Seminar Series
              in cooperation with
         MU Sinclair School of Nursing
                  Chris Fender, Interim Director
Harriet Francis - Sr. Licensing & Business Development Associate
    Office of Technology Management & Industry Relations
                  University of Missouri System

        “Compliance in Technology Management”
                           Wednesday, March 18, 2009
                                Noon-1:00 p.m.
                              Acuff Auditorium

 1.   To describe the Office of Technology Management & Industry Relations
 2.   To explain the Bayh-Dole Act.
 3.   To review the collected rules and regulations.
 4.   To explore the disclosure process.
 5.   To describe the patent process.
 6.   To discuss faculty startup companies and the Conflict of Interest process.

                                                                                   COMPLIANCE CORNER   9
New OCR Guidance for Health Care                        The revised Medicare Physician Guide:
Providers and Consumers on the HIPAA                    A Resource for Residents, Practicing
Privacy Rule and Communications with a                  Physicians, and Other Health Care
Patient’s Family, Friends, or Others Involved           Professionals (October 2008), which
in the Patient’s Care                                   offers general information about the
                                                        Medicare Program, becoming a Medicare
The Department of Health and Human Services             provider or supplier, Medicare
(HHS) Office for Civil Rights (OCR) has                 reimbursement, Medicare payment
published two new HIPAA Privacy Rule                    policies, evaluation and management
guidance documents – one for health care                services, protecting the Medicare Trust
providers and one for consumers – that discuss          Fund, inquiries, overpayments, and
when a health care provider may share a                 appeals, is now available in downloadable
patient’s health information with the patient’s         format from the Centers for Medicare &
family, friends, or others involved in the              Medicaid Services Medicare Learning
patient’s care. These new guides answer                 Network at
common questions about these permitted and              http://www.cms.hhs.gov/MLNProducts/dow
important communications and target an area of          nloads/physicianguide.pdf .
the HIPAA Privacy Rule that is frequently misunderstood by health care providers and patients

The provider guide is available at http://www.hhs.gov/ocr/hipaa/provider_ffg.pdf.
The consumer guide is available at http://www.hhs.gov/ocr/hipaa/consumer_ffg.pdf.

We hope you find these new resources helpful. For more information on the HIPAA Privacy Rule,
including guidance on specific provisions, fact sheets, and frequently asked questions, please visit
the OCR Privacy Rule Web Site at http://www.hhs.gov/ocr/hipaa.

Are You Having Difficulty Getting Answers to Coding
and Compliance Questions?
You may find the answers in the Compliance Auditing Manual on DocuShare at

You can always contact the Office of Corporate Compliance by calling 573-884-0632 or 573-884-
1729. You may also contact individuals within the department for personal attention.

Mike Lynch, Chief Compliance Officer 573-884-0632
Darlene Ornburn, Compliance Administrator 573-882-3295
Lisa Oswald, Coordinator - Corporate Compliance 573-882-3293

                                                                           COMPLIANCE CORNER           11
                                   Bulletin Board

                                Coder/Biller Meetings 2009
                                                 2 – 3 p.m.
March 19th - Hold Bills - Tami Clark, Registration - Quarterdeck Bldg., Rm 118
April 16th – Diagnosis Coding - GL – 11
May 21st – E/M coding – GL11
June 18th – DRG’s – GL-11

                        Show-Me Chapter AAPC
                        Exam Dates and Meetings                                Satisfy your
  Date           Location                        Topic                           Annual
 3/12/09          QD118                                                      Code of Conduct
 4/9/09           CRH Pavilion Conference Room                                Requirement
 May 9th          EXAM
 6/11/09          QD237
 August 8th       EXAM                                                       Join Lisa Oswald
 8/13/09          QD118
 9/10/09          QD228
                                                                                 for a live
 10/8/09          CRH Pavilion Conference Room                              presentation of the
 11/12/09         QD228                                                        2009 Code of
 November 14th    EXAM
 12/10/09         QD228                                                          Conduct

                                                                             Acuff Auditorium
                                                                                 Friday, April 3rd

                                                                                   4 – 5 p.m.

                                                                             COMPLIANCE CORNER       12

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