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Manual Medical Review of Therapy Services

Effective October 1, 2012, according to the Balanced Budget Act of 1997 enacted financial limitations on outpatient physical therapy, occupational therapy, and speech-language pathology services in all settings except outpatient hospital. Exceptions to the limits were enacted by the Deficit Reduction Act, and have been extended by legislation several times. 

Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) extended the therapy caps exceptions process through December 31, 2012, and made several changes affecting the processing of claims for therapy services. Suppliers and providers will continue to use the KX modifier to request an exception to the therapy cap on claims that are over the 2012 cap amounts -- $1,880 for occupational therapy services and $1,880 for the combined services for physical therapy and speech-language pathology. Use of the KX modifier indicates that the services are reasonable and necessary and that there is documentation of medical necessity in the patient's medical record. 

MCTRJCA also established a requirement for manual medical review of claims over $3,700. In mid-September 2012, CMS will mail a letter to beneficiaries who have received therapy services in Calendar Year (CY) 2012 over $1,700. The CMS letter will inform them of the $1,880 therapy cap, the exceptions process and that, if services over the cap do not qualify for the exception as medically necessary, that they will be responsible for the charges.

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CPC sample question # 15

Indications: Endometrial carcinoma.

Findings: At the time of entrance into the operating room, the abdomen had been previously opened. The right infundibulopelvic ligament was in the process of being skeletonized; the left was already clamped, cut, and ligated with chromic suture. The right ureter was identified, as was the left. No apparent injury was noted. The patient received Indigo Carmine intraoperatively; there was no spillage of dye. The uterus was about 8 week’s size. The tubes and ovaries appeared normal. There were dense adhesion of the colon to the rectovaginal spectrum.

Procedure: After successful anesthetic induction and prepping of the abdominal wall with Betadine solution, the patient was draped in a sterile manner and a midline incision was made. The left adnexa was taken by skeletonizing the infundibulopelvic ligament. An attempt to skeletonize the right ureter was hampered by the patient’s obesity. After a 45 minute attempt, skeletonization of the right ureter was accomplished then doubly clamped, cut, and ligated x2 with 0-silk suture the right infundibulopelvic ligament. The vesicouterine flod and rectovaginal fold were taken down with sharp dissection. The uterine vessels were taken bilaterally with Heaney clamps, cut, and ligated with 0 chromic sutures. Successive pedicles of the cardinal ligaments and uterosacral ligaments were taken with clamps and each pedicle was cut and ligated with 0 chromic suture. The angle of the vagina was taken in a similar fashion. The specimen was released and handed off the field. The cuff was then run using a 0 chromic suture in a running locking fashion. A drain was then placed. The pelvis was inspected and noted to be hemostatic, Bleeding points were taken with electrocoagulation.

The patient was markedly obese. It was difficult to identify the ureter near the bladder on the right and left side; however, at the level of the uterine vessels they were identified and there was no spillage of blue dye within the abdominal cavity. At this point, given the patient’s obesity, it was elected to conclude the procedure. Washing have been preciously obtained. An omental biopsy was also obtained. The abdomen was closed using an 0 PDS suture in a Smead-Jones fashion. The subcutaneous layer was lavaged. Bleeding points were cauterized with electrocoagulation. The skin was closed with staples. The patient was transferred to the recovery room in stable condition.

a.    58260, 58700, 58940, 58940-50, 182.0
b.    58120-50, 182.0, 198.82
c.    58150, 182.0
d.    58260, 58720-50, 195.2                    


CPC sample question # 14

Indications: This is a third follow-up dilation for this patient. He had a pyloric channel uncer, which has been slow to heal and has hadsubsequent pyloric stenosis and obstruction. This is a repeat evaluation and dilation.

Procedure: With the patient in the left lateral decubitus position, the endoscope was inserted into the proximal esophagus and advanced to the Z-line. The esophageal mucosa was unremarkable. The stomach was entered, revealing normal gastric mucosa. Mild erythema was seen in the antrum. The pyloric channel was again widened. However, the ulcer as previously seen was well healed with a scar. The pyloric stenosis was still present, somewhat obstructing the pyloric channel. With some probing, the 11 mm endoscope was introduced into the second portion of the duodenum revealing normal mucosa. Marked deformity and scarring was seen in the proximal bulb. A 15 mm ballon was placed across the stricture and dilated to maximum pressure and withdrawn.

There was minimal postprocedural bleeding. Much easier access in to the duodenum was accomplished after the dilation. Follow-up biopsies were also taken to evaluate Helicobacter noted on a previous examination. The patient tolerated the procedure and was discharged in good condition.

Impression: Pyloric stenosis secondary to healed pyloric channel ulcer dilated as described.

Plan: Check on biopsy, continue prilosec for at least another 30 days. At that time, a repeat endoscopy and final dilation will be accomplised. He will almost certainly need continous H2 blocker therapy to avoid recurrence of the ulcer.

a.    43235, 43245-59
b.    43245
c.    43245, 43239-59
d.    43249


CPC sample question # 13

Indication: Chronic pelvic pain.

Procedure: The patient was taken to the operating room and IV infusion was performed. She was placed on the operating table in the dorsal supine position. Following induction of general endotracheal anesthesia, she was placed in the dorsal lithotomy position. Her abdomen and perineum were prepped and draped in the usual sterile fashion for the laparoscopy.

The cervix was visualized with a weighted speculum and a manipulator was placed. The speculum was removed and a picture of the laparoscopic portion of the procedure was tacken.

A 1 cm long vertical incision was made at the umbilicus. A Veress needle was introduced into the abdominal cavity. The umbilical site a suprapubic site were injected with 25 percent Marcaine with epinephrine prior to the incision. The abdomen was insufflated with CO₂  gas. The Veress needle was removed and a 10 mm trocar was placed in the umbilical incision without difficulty. The scope was placed through the sleeve and under direct visualization, a second puncture site was made with a 5 mm trocar. It was approximately 3 cm from the pubic symphysis in the midline. The pelvis was noted to be as previously described. The ovarian cyst was aspirated and approximately 20 cc of serous obtained. The area of fleshy appearing endometriosis along the right uterosacral ligament was cauterized. Hemostasis was assured.

The CO2 gases were allowed to escape and both trocar sleeves were removed with direct visualization and hemostasis noted. Each site then closed using 4-0 Vicryl in a subcuticular fashion. Sterile dressings were applied.

a.    49322, 625.9, 617.3, 620.2
b.    49323, 625.9, 617.1
c.    49322, 620.2, 617.3
d.    49323, 625.9, 620.2 


CPC sample question # 12

Description of Procedure: Left heart catherterization, left ventriculography, and selective coronary arteriography were performed percutaneously via the right femoral artery under local xylocaine anesthesia. At the conclusion of the procedure, the catheters were withdrawn and hemostasis was obtained with firm pressure at the puncture site. The procedure was uncomplicated and the patient tolerated the procedure well.

Left Ventriculography: The left ventriculography was performed with the patient in the right anterior oblique position. The left ventricle was normal in size and demonstrates normal systolic function. There is a 1 + mitral insufficiency. There are frequent premature ventricular contractions noted with ventriculography.

Coronary Arteriography: Selective coronary arteriography was performed with the patient in various right anterior and sagittal oblique positions. The left main coronary artery is heavily calcified and irregular. The left main coronary artery is narrowd approximately 30-40 percent. The left anterior descending coronary artery is large in caliber and extends over the apex. The left anterior descending artery provides several diagonal branches. The first diagonal branch is medium in caliber and narrowed 70 percent proximally. The left anterior descending coronary artery is then heavily calcified in its proximal half. It is hazy following the first diagonal branch. The second diagonal branch is small and irregular, but free of significant disease. The left anterior descending artery is narrowed approximately 60-70 percent after the second diagonal branch at the junction between proximal and middle thirds of the vessel. The distal left anterior descending artery is calcified and irregular, but free of significant obstructive disease.

The left circumflex coronary artery is calcified and nondominant. The left circumflex coronary artery provides a medium caliber first obtuse marginal branch. This is narrowed 90 percent proximally. The left circumflex coronary artery is narrowed 90 percent in the atriventricular groove at the level of the takeoff of the first marginal branch. The second obtuse marginal branch is medium to large  in caliber and irregular, but free of significant disease. The rightcoronary artery is large and dominant. The right coronary artery is subtotally occluded in its proximal on third, with an eccentric plaque that appears to have a resemblance to the intraluminal thrombus. The distal right coronary arteery is irregular and calcified. The distal right coronary artery may also be seen filling via-left-to-right collateral circulation.

Conclusions: 1. Coronary artery disease, with severe, triple vessel. 2. Normal left ventricle systolic function.

Comments: The patient has rest angina with severe triple vessel coronary artery disease and coronary artery bypass surgery is recommended.

a.    93514, 93543, 93545, 93555, 93556
b.    93510, 93543, 93545, 93556
c.    93510, 93555, 93556
d.    93510, 93543, 93545, 93555, 93556 


CPC sample question # 11

Preoperative Diagnosis: Acute respiratory failure and protein-caloric malnutrition.

Postoperative Diagnosis: Acute respiratory failure and protein-caloric malnutrition.

Procedures performed : Tracheostomy and percutaneous gastrostomy tube placment.

Findings: Esophagus and pylorus were normal. Estimated Blood Loss: Minimal.

Indications: Respiratory failure and malnutrition.

Description of Procedures: This 78-year-old patient underwent induction with general anesthesia. After having placed a shoulder  roll, the neck was prepared and drapped in the usual sterile fashion.

An open cutdown to the trachea was performed using a #10 blade sclpel. Dissection was undertaken utilizing the Bovie cautery. The strap muscles were divided in the middle and the thyroid was pulled superiorly. A tracheal hook was placed in the trachea and the endotracheal tube was then utilized and the needle was introduced into the trachea. The wire was fed and the appropriate steps utilizing the dilators were undertaken. A tracheostomy was placed.

Placement was confirmed and the trachea was secred into place utilizing interrupted nylon sutures. The incision was closed with an additional interrupted nylon suture.

Attention was then turned towards the placement of a feeding tube. An esophagogastroduo-denoscope was placed via the month and the esophagus was viewed. It was felt to be normal; therefore, the stomach was entered. There was no evidence of abnormality and the pylorus was well visualized. The abdominal wall was also prepped and draped at this time. The patient was morbidly obese and I was not able to gain adequate transillumination after entering the stomach and duodenum. By pushing on the abdominal wall, after determining location, a cutdown was made through the skin overlying the stomach utilizing a scalpel and Bovie cautery.

A retractor was placed. I was then able to transilluminate through the abdominal wall. A standard percutaneous endoscopic gastrostomy tube placement was performed. The needle was introduced and visualized as it passed. The wire was fed in and the grasper was utilized to grasp the wire. It was pulled out of the patient’s month along with the scope. The tube was secured to the wire and the wire was pulled back out through the abdominal wall, placing the percutaneous endoscopic gastrostomy tube. At this time, the scope was reintroduced and the percutaneous endoscopic gastrostomy tube placement was confirmed.

The abdominal wall was closed utilizing 3-0 Vicryl in an interrupted fashion followed by interruped 3-0 Ethilon sutures.

All sponge, needle, and instrument counts were correct. The patient left the operating room in good condition and there were no complications. Blood loss was minimal.

a.    43246, 31603-59, 518.82, 263.8
b.    43246, 31600-59, 518.81, 263.9
c.    43752, 31600-59, 480.1, 261
d.    43256, 31612-59, 786.09, 263.9


CPC sample question # 10

Preoperative Diagnosis: Pelvic mass, probable ovarian neoplasm.

Postoperative Diagnosis: Neurofibroma of the retroperitoneum.

Anesthesia: General.

Findings: Uterus, tubes, and ovaries were unremarkable bilaterally; however, the ureters were adherent to the bladder base and upper rectum; very large retroperitoneal mass extending to the pelvic brim. Estimated  Blood  Loss: 500 cc.

Indications: Pelvic pain.

Description of procedure: The patient was taken to the operating room and intubated under general tracheal anesthesia. Her abdomen was prepped and draped in the usual sterile manner. A Foley catheter was placed in the bladder under sterile conditions. A vertical midline skin incision was made with the knife. The abdomen was opened in layers. After entry into the peritioneal cavity, washings were taken from all quadrants of the abdomen and pelvis and sent for peritoneal cytology. 

Exploration of the abdomen revealed a smooth liver edge and the kidneys were bilaterally present and normal. The periaortic area palpated normal and there were no enlarged lymph nodes in this area. The patient was noted to have a totally normal uterus, bilateral tube and ovaries.

A very large retroperitoneal mass that extended to the pelvic was noted. It measured 7.5 cm and extended posterior to the external iliac artery and vein and down into the hollow of the sacrum. The ureter was draped over it and it was densely adherent to the bladder base as well as the paravaginal area and the upper rectum posteriorly.

The retroperitoneal space was opened and the pelvis vessels were identified. The ureter was noted to be coursing over the mass. The ureter was dissected free with sharp dissection. Sharp and blunt dissection was then used to shell out the mass. Which was extremly difficult.

The patient had many small vessels leading to the mass, both coming from the erea of her bladder base and the right pelvic sidewell as well as the sacral hollow. Hemoclips were used for hemostasis as well as 2-0 silk ties. The dissection was quite difficult and tedious and continued down to the final attachment with the proximal rectum and paravaginal area. It was dissected off using sharp dissection. There were several bleeding areas that were controlled using pressure, silk ties, and Avitene.

There was an oozing tumor bed where this tumor had enveloped the area. This, again, was controlled using mostly Avitene and pressure. The frozen section returned as benigh neurofibroma.

The pelvis was checked for bleeding. It was felt to be hemostatic. The uterus, tubes, and ovaries were placed back in normal position. The colon was inspected and felt to be uninjured. The bladde base was rather friable secondary to the dissection and there was hematuria. The base of the bladder was inspected and there was no evidence of any direct injury. The urete was dissected out were it had draped over the colon down to the base of the bladder. It also appeared uninjured. The other ureter was checked and felt to be normal on the left side. The abdomen was then closed using 0 Vicryl interrupted mattress closure. The skin was closed using a running subcuticular suture of 3-0 Vicryl.

The patient left the operating room in stable condition. She was awake and extubated. The sponge, needle, and instrument counts were correct at the case. She had slightly bloody urine at the complection of the procedure. Blood loss was 500 cc.

a.    49204, 211.8
b.    49203, 237.70, 239.5
c.    49204-22, 233.9, 237.71
d.    19329, 239.5, 237.72


CPC sample question # 9

Preoperative Diagnosis: Cataract, left eye.

Postoperative Diagnosis: Cataract, left eye.

Anesthesia: Retrobulbar, IV sedation.

Anesthesia: Phacoemulsification with intraocular lens implantation in the left eye.

Indications: The patient is an elderly is an elderly female who has had blurry vision in the left eye for six months causing her difficulty while driving and reading. Her best correct visual acuity is 20/40 with a glare of 20/80. She has a 2+ posterior subcapsular cataract.

Description of procedure: The patient was taken to the operating suite and placed in the supine position. A 50:50 mixture of 2 percent Lidocaine and 0.75 percent Marcaine, both without Epinephrine, was prepared. After adequate sedation, 4 cc of this mixture was injected in a retrob-ulbar fashion. Gentle ocular massage was applied to the eye for several minutes.

After adequate ocular akinesia was obtained, the patient was prepped and in the usual sterile fashion for ocular surgery.  A wire lid speculum was inserted into the left eye. A supersharp blade was used to create an inferior paracentesis port. Viscoelastic was used to deepen the anterior chamber and a clear cornea temporal incision was made. The cystotome needle and forceps were used to create a continuous capsulorhexis. Balanced salt solution was used to hydrodissect and hydrodelineate the nucleus. The nucleus was then noted to rotate freely within the bag.

The phacoemulsification hand-piece was introduced into anterior chamber and the nucleus was carefully removed. The remaining cortex was removed using the irrigation/aspiration hand-piece. A capsule polisher was used to remove posterior capsular opacities off the lens. Viscoelastic was injected into the anterior chamber. The wound was enlarged with a keratome. The intraocular lens, with a power of 23.0 diopters, was removed from its bag, inspected for flaws and rinsed thoroughly with balanced salt solution.

The lens was folded and inserted through the temporal incision into the capsular bag and removed into position with the Lester hook. The lens was noted to be in good condition. The irrigation/aspiration hand-piece was reintroduced into the eye to remove the remaining Viscoelastic.

The wound was hydrated with balanced salt solution and found to be watertight with gentle pressure and Weck-cel sponges. A mixture of Solu-Medrol and Ancef was injected into the inferior conjunctiva. The lid speculum was removed. Maxitrol ointment was placed into the left eye, along with a light pressure patch and shield.

All sponge, needle, and instrument counts were correct. The patient left the operating room in excellent codition and there were no complications, Estimated blood loss was zero.


CPC sample question # 8

Preoperative Diagnosis: Status post left ureterolithotomy.

Postoperative Diagnosis: Status post ureterolithotomy; calculus of right renal pelvis.

Operative technique: The patient was brought to the cystoscopy suite on an outpatient basis status post left ureterolithotomy (6 hours ago) with an indwelling double J ureteral stent placed during surgery. She was brought in for stent removal. Patient was placed in the dorsal lithotomy position, prepped, and draped in the usual sterile fashion. The 21 scope was introduced with cystoscopy findings grossly normal. There was some obvious edema around the orifice of the stent. The stent was grasped with alligator biopsy forceps and removed without difficulty. She tolerated the procedure well. Surgeon will attempt to alkalinize the patient’s urine to dissolve the stone in her right pelvis, which has remained asymptomatic.

a. 52310
b. 52315
c. 52310-58
d. 52290      


CPC sample question # 4

Procedure Reason: Subdural hematoma. Evaluation for AVM.

Medications: 2 mg Versed IV, 100 mcg Fentanyl IV.

Complications: None.

Contrast: 115 cc of Omnipaque-300.

Risks, benefits, and alternatives to the procedure were explained to the patient and informed written and oral consent was obtained.

A 21 gauge micropuncture needle was used to puncture the left common femoral artery using fluoroscopic guidance. An 018 wire was placed into the artery and over this a 5 French  dilator. A 5 French vascular sheath was placed in the left common femoral artery. Through the sheath, a guidewire and 5 Frence Weinberg catheter were placed into the ascending aorta.

Procedure: Contrast was injected, and digital images of the aortic arch were obtained. The catheter was mainpulated to select both vertebral arteries, the right common carotid artery and the left common carotid artery. Contrast was injected in each, with imaging in the head and neck from each selection site.

The catheter was removed, and pressure was applied in the interventional recovery room. Borth extrmities were evaluated for pulse post 30 minutes from the procedure and were normal.

Findings: Aortic arch injections: The origin of the vessels coming off the aortic arch are normal in appearance, with no evidence of stenosis. Right vertebral artery injection: The artery is patent with no stenosis. The posterior fossa vasculature is normal in appearance. The posterior arteries have normal course with no evidence of vasculitis.

Left vertebral artery injection: The artery is patent with no stenosis. The posterior fossa vascu-lature is normal in apperance. The posterior arteries have normal course, with no evidence of vasculitis.

Right common carotid artery injections: No carotid stenosis or evidence of dissection. Imaging of the head reveals a patent anterior communicating and right posterior communicating arteries, with no AVM or aneurysm identified. Normal venous phase is imaged.

Left common carotid artery injections: No carotid stenosis stenosis or evidence of dissection. Imaging of the head reveals a patent anterior communicating and right posterior communicating arteries, with no AVM or aneurysm identified. Normal venous phase is imaged.

Provide the correct procedure code(s) for this procedure.

Impression: Normal four vessel arteriogram.



CPC sample question # 7

Procedure: ERCP with sphincterotomy and removal of common duct stone

Indication for Procedure: The patient is a 62-year-old women with documented obstructing common duct stone. She is status post T-tube insertion for creation of a biliary drainage tract. She now present for sphincterotomy and stone removal.

Description of Procedure: The patient was brough to the endoscopy suite and sedated with IV Versed and Fentanyl. After the pharynx was anesthetized with Xylocaine spray, a guidewire and snare were advenced through the external biliary drain site into the duodenum.

Next the side-viewing duodenoscope was inserted per os and advanced into the esophagus, stomach, and duodenum. Esophageal, gastric, and duodenal mucosa were all noted to be unremarkble. The scope was positioned in place and a guidewire was grasped by the external snare and pulled up into the bile duct and out through the skin.

The sphincterotome was then advanced over the guidewire up into the bile duct and positioned across the papilla of Vater. The papilla was noted to be lying in the base of a large duodenal diverticulum. The sphincterotomy was then performed to a total of 1.0 cm. There was a moderate amount of bleeding that resolved spontaneously. Estimated blood loss was less than 25 cc. Next a 1.1 mm. balloon was advanced over a guidewire up into the bile duct and pulled out clearing the duct of all gravel and small stone material.

Before concluding the procedure, a follow-up cholangiogram was performed and revealed no further evidence of stones within the duct. Ther was free flow of contrast out to the T-tube site, revealing a well-established drainage tract. A mild stricture of the right hepatic duct was observed, but no residual stones were seen. During the procedure the pancreatic duct was also visualized and appeared to be patent and of normal caliber. It is anticipated that excellent drainage has been established. The procedure was thus terminated and all instruments were withdrawn. The patient tolerated the procedure well. She will be discharged after recovery from sedation.


CPC sample question # 6

Preoperative Diagnosis: Left carpal tunnel

Postoperative Diagnosis: Same

Anesthesia: Bier Block.

Procedure Performed: Left carpal tunnel release; median epineurolysis.

Findings: Median nerve was adherent but no masses.

Indication: This has documents carpal tunnel syndrome based on electromyelogram.results and desires elective release.

Procedure: The patient was tacken to the operating room, positioned supine on the operating room table, and anesthesia was administered. The limb was prepped and draped in sterile fashine. The limb was elevated using a compressive bandage and the tourniquet was inflated to 225 mm Hg. The gauge was tested for oscilation. Local infiltration with 1 percent Xylocaine into the medial and ulnar position were performed.

An incision was made deep through the subcutaneous tissues. Bleeding points were electro-coagulated using bipolar cautery and the skin edges were handled atraumatically. The palmar fascia was identified and incised and the transverse carpal ligament was exposed. A wide release was achieved by opening its ulnar-most aspect and carrying the dissection distally to crossing the ulnar neurovascular bundle and proximally under vision in the antebrachial fascia of the forearm. The median nerve was adherent and an epieurotomy was carried out. The thenar branch was carefully protected and the wound was irrigated carefully. Hemostasis was achieved and closure was accomplished with 5-0 nylon sutures applied to the skin to ensure good coaptation of the skin edges. A sterile compressive dressing was applied with antibiotic-laden, nonadherent gauze. A volar cock-up wrist splint was applied with the thumb and digits free and the wrist in a moderate dorsification position.

All sponge, needle, and instrument counts were correct. There were no operative complications. The tourniquet was deflated and the patient was returned to the recovery room in good condition. Estimated blood loss was less than 50 cc.


CPC sample question # 5

Operations Performed: Esophagogastroduodenscopy and Maloney dilation.

Indications for Procedures: This is a 36-year-old femal with rheumatoid arthritis who has been developing progressive dysphagia over the last week. The patient had an outpatient attempt at esophagram in the emergency room, which suggested she had a proximal esophageal stricture; therefore, this examination is being done to evaluate this abnormality.

Description of Procedures: Informed consent was obtained from the patient. Demerol 60 mg, Versed 3 mg were given intravenous slowly for sedation. The patient was placed in the left lateral position.

The GIF-100 EGD scope was passed into the esophagus via the no-touch technique. The esophagus did not demonstrate a definite stricture endoscopically. Whether I passed it on inserting the scope, I cannot be certain. Nevertheless, there was certainly no resistance to the passage of the 9 mm scope into the proximal esophagus. The esophagogastric junction was at 40 cm. Stomach was entered and found to be within normal li,its, without ulceration. The duodenal bulb and descending duodenum were both normal. The scope was then withdrawn and Maloney dilators 36, 42, 46, and 52 were passed sequentially without difficulty.

The patient tolerated both procedures well and returned to the recovery room in good condition.

Impression: 1. Possible proximal esophageal stricture. 2. Status post Maloney dilation.


CPC sample question # 3

Preoperative Diagnosis: Benign prostatic hypertrophy with urinary obstructive symptoms

Postoperative Diagnosis: Benign prostatic hypertrophy with urinary obstruction

Procedure: Transurethral resection and vaporization of the prostate. Insertion of suprapubic catheter.

Anesthesia: General.

Description of procedure: With the patient in the dorsal lithotomy position after   successful induction of general endotracheal anesthesia, the patient’s penis and perineum were prepped and draped in the usual sterile fashion. A #24 French resectoscope sheath with a Timberlake obturator was inserted into the urethra. The bladder was then filled with irrigating solution.

Next a  #16 suprapubic catheter was placed into the bladder via a small stab wound 1 inch above the pubic bone. Correct placement of the catheter was verified with the resectoscope lens. The balloon was then inflated with sterile water and connected to an outlet tube for continuous irrigation. Resection was then begun going first from the 3 o’clock to the 6 0’clock position, and then from the 6 o’clock to the 9 o’clock position. Resection was followed by electric current vaporization using the Bugbee electrode, again from the 3 o’clock to 6 o’clock position, and then from the 6 o’clock to the 9 o’clock position, effectively removing all hyper-trophied prostate tissue. It should be noted that at this point examination of the bladder neck revealed signs of contracture. Therefore it was considered prudent to release the contracture by making an incision on either side of the bladder neck.

The prostate chips were thoroughly evacuated with the Ellis evacuator. After verifying adequate hemostasis, the bladder was emptied of irrigating solution. A #24 Frence 3-way Foley cath-eter was inserted and the balloon was blown up to 40 cc. The balloon was then deflated and removed and the Foley catheter was hooked up to continuous irrigation. A sterile compression dressing was applied to the suprapubic incision. The patient tolerated the procedure well and was taken to the Recovery Room in satisfactory condition.


CPC sample question # 2

Preoperative Diagnosis: Complete heart block.

Postoperative Diagnosis: Mobitz Type II heart block.

Anesthesia: Moderate conscious sedation.

Description of procedure(s): The patient was taken to the operating room and placed on the table in the supine position. After laryngeal mask anesthesia, the patient’s left chest was prepped and draped in the usual sterile fashion. A longitudinal incision was made beneath the clavicle down to the pectoral fascia. A prepectoral fascial pocket was fashioned inferomedially and superolaterally. Using fluoroscopic guidance and a percutaneous technique, an atrial lead was placed in the right atrium and screwed in place. A ventricular lead was placed in the floor of the right ventricle. It was screwed in place. Atrial threshold was 1.2 V; width 0.5 milliseconds; current was 3.0 mA; resistance was 489 ohms, and P waves were 11.7 mV and stable. Slew rate was 2.2 V/sec. Ventricular threshold was 0.5 V; width 0.5 milliseconds; current was 3.0 mA; resistance was 663 ohms, and R waves were 11.7 mV and stable. Slew rate was 3.30 V/sec. These leads were connected to a pulse generator. The pulse generator was placed in the floor of the antibiotic irrigated pocket and secuted using silk suture. The leads were secured using multiple silk sutures. The wound was irrigated and closed with layers of Vicryl and subcuticular Vicryl to the skin.

The patient tolerated the procedure well and was transferred to the recovery room in good condition. Fluoroscopy showed good lead position and no evidence of pneumothorax or fluid collection in the left chest. All spong, needle, and instrument counts were correct. Blood loss was minimal.



CPC sample question # 1

Preoperative Diagnosis: Dupuytren’s contracture

Postoperative Diagnosis: Same

Procedure Performed: Biopsy of mass, volar aspect right hand

Anesthesia: Medial and ulnar nerve block

Findings: This 48-year-old white female has been struggling with a limp over the volar aspect of her right hand for several months. The mass is firm, fixed, and appears to getting larger. The patient notes discomfort in this region when she grasps objects such as a broom handle. Differential diagnosis includes early Dupuytren’s contracture vs. epidermoid inclusion cyst. Excision was recommended and the patient presents for same at this time. She is aware of the risks and benefits of the procedure and wishes to proceed.

Description of procedure: After adequate anesthesia was achieved, the right upper extremity was prepped and draped in the standard sterile orthopedic fashion. A modified Brunner incision was made over the fifth ray and dissection carried down through subcutaneous tissue. The neurovascular bundles of the fourth and fifth rays were identified and protected. The mass was isolated and noted to extend off the pretendinous fascia in a palmar direction. The pretendinous fascia was excised over the fifth ray for a distance of approximately 3 cm. The mass was mobilized off the subcutaneous tissue with a #69 Beaver blade. The remaining skin over this area was noted to be thin. Pretendinous fascia over the fourth ray was also partially excised as the mass was noted to be adhesed at this site as well. Flexor tendons were freed and intact. Further exploration of the wound revealed no evidence of significant involvement of the pretendinous fascia up into the MCP area distally of either the fourth or fifth ray.

Once all dissection was completed the wound was copiously irrigated with Kefzol solution. A 4-0 PDS suture was used to close the deep tissues and the skin was closed with 4-0 nylon. The tourniquet was released and the operative site was noted to turn appropriately pink with blood return. A sterile op site dressing was applied and the patient was returned to the recovery area is stable condition.

Pathology report returned with features consistent with Dupuytren’s contracture.


Answers for CPC sample Questions

CPC sample question # 1

CPT 26123, 26125, ICD-9-CM 728.6

26123 is used for reporting the Fasciectomy, with release of 1 single digit and 26125 is for the additional dight.

Diagnosis code 728.6 is used to report the Dupuytren’s contraction

CPC sample question # 2

CPT 33208, ICD-9-CM 426.12

33208 is reported for the pacemaker with the atrial and ventricular electrodes and 71090 is reported for the fluorscopic guidance.

420.12 identifies the Mobitz Type II atriovertricular block (AHA 2007 second quarter).

CPC sample question # 3

CPT 52601, 51040-59, ICD-9-CM 600.01, 599.69

The transurethral resection and vaporization of the prostate. The prostate tissue was destroyed using electric current vaporization and 51040 for the suprapubic catheter insered at the end of the procedure. Code 51040 would need a modifier 59 appended.

600.01 is reported for the hypertrophy with urinary obstruction

599.69 is reported as under the instruction for 600.01 an addition code is reported for the obstruction using code 599.69

Reference: Coding Clinic; 4th quarter 2003

CPC sample question # 4

CPT 36215-LT, 36217-RT, 36216-LT, 36218-RT, 75650, 75685-RT, and 75685-LT, 75680, 75671

The placement of the catheter (and the injection) into the aortic arch is not reported because a nonselective catheter placement is not separately reported if was followed by selective catheter placement.

36217-RT is reported for selection of the right vertebral artery because it is a third order vessel. 36216-LT is reported for selection of the left vertbral artery because it is 2nd order vessel. The add-on code 36218-RT is reported for selection of the right common carotid artery because it is an additional 2nd order vessel within the innominate family.

75650 is reported for imaging of the aortic arch injection.

75685-RT and 75685-LT are reported for the imaging of the right and left vertebral arteries. Note that there is no bilateral code for vertebral imaging. Also, according to the July 2001 CPT® Assistant, the 50 modifier should not be reported with radiology imaging codes

The common carotid injection allowed the physician to study arteries in both the neck and head areas. 75680 (bilateral code) is reported for imaging of both the left and right carotid arteries in the neck (ie, cervical) area. 75671 is reported for imaging of both the left and right carotid arteries in the head (ie, cerebral) area. Code 75671 is a bilateral procedure and reported only once

CPC sample question # 5

CPT 43235, 43450, ICD-9-CM 787.20

CPC sample question # 6

CPT 64721, ICD-9-CM 354.0

CPC sample question # 7

CPT 43262, 43264, 74328, 74300, ICD-9-CM 574.51

CPT code(s) In the Index, “cholangiopancreatography with surgery” lists a series of code in the 43262-43269 range. A review of the code descriptions in this range shows that two codes are required to describe the procedures performed: 43262, ERCP with sphincterotomy/papillotomy; and 43264, ERCP with endoscopic retrograde removal of stone(s) from biliary and/or pancreatic ducts.

Code 74328 is reported for the biliary catheterization. (The scope was positioned in place and a guidewire was grasped by the external snare and pulled up into the bile duct out through the skin.)

74300 (Before concluding the procedure, a followed-up cholangiogram was performed and revealed no further evidence of stones within the duct). Since there was no mention of when the first cholangiogram was performed we can only report it once.       

Diagnosis code reported is 574.51, Calculus of bile duct without mention of cholecystits, with obstruction

CPC sample question # 8


CPC sample question # 9

CPT 66984, ICD-9-CM 366.14

66984 Reports the cataract extraction with the intraocular lens implant.

366.14 Identifies the posterior subcapsular senlie cataract.

CPC sample question # 10

49204, 211.8

CPC sample question # 11

43246, 31600-59, 518.81, 263.9

CPC sample question # 12

93510, 93543, 93545, 93555, 93556 

CPC sample question # 13

49322, 620.2, 617.3

CPC sample question # 14

43245, 43239-59

CPC sample question # 15

58150, 182.0


What are the three levels of Physician Supervision?

CMS recognizes three primary levels of physician supervision. In the context of outpatient diagnostic services, these are defined as:

1. General supervision: The procedure is furnished under the physician’s overall direction and control. The physician must order the diagnostic test and is responsible for training staff performing the tests, as well as maintaining the testing equipment. He or she does not need to be present in the room during the procedure.

2. Direct supervision: In the physician office, the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.

3. Personal supervision: A physician must be in attendance in the room during the performance of the procedure. Regardless of location, if a physician personally provides the entire service, supervision requirements are not a concern.

What is the CPT code to be reported by the transferring physician when a neonate is transferred to critical care on the same day that initial intensive care services were performed?

According to CPT 2012 guidelines, when a neonate is transferred from intensive care (99477) to a lower-level care, the transferring physician should report subsequent hospital care (99231-99233). If the neonate or infant must be transferred to critical care on a day when initial or subsequent intensive care services have been performed, the transferring physician reports either the critical care (99291-99292) or the intensive care (99477), but not both. The receiving physician reports subsequent inpatient neonatal or pediatric critical care (99469, 99472).

Types of CLIA Certificates and CPT code details

CPT Codes that requires CLIA Certificate of Waiver

G0394     82010    82465    82962    83605    84460    85610    87210
80061    82044    82523    82985    83655    84478    85651    87449
80101    82055    82570    83001    83718    84703    86294    87804
80178    82120    82679    83002    83721    84830    86308    87807
81002    82270    82947    83026    83880    85013    86618    87808
81003    82271    82950    83036    83986    85014    86701    87880
81007    82272    82951    83037    84443    85018    86703    87899
81025    82274    82952    83518    84450    85576    87077    89300

CPT codes that requires Certificate of Compliance, Accreditation, or Registration

Please note: The below list includes all codes under Certificate of Waiver and Certificate for Provider-Performed Microscopy Procedures

G0103     81005    82533    83050    83937    84520    85610    86632    86972    87420    88142
G0123     81007    82540    83051    83945    84525    85611    86635    86975    87425    88143
G0124     81099    82541    83055    83950    84540    85612    86638    86976    87427    88147
G0141     82000    82542    83060    83970    84545    85613    86641    86977    87430    88148
G0143     82003    82543    83065    83986    84550    85635    86644    86978    87449    88150
G0144     82009    82544    83068    83992    84560    85652    86645    87001    87450    88152
G0145     82010    82550    83069    84022    84577    85660    86648    87003    87451    88153
G0147     82013    82552    83070    84030    84578    85670    86651    87015    87470    88154
G0148     82016    82553    83071    84035    84580    85675    86652    87040    87471    88155
G0306     82017    82554    83080    84060    84583    85705    86653    87045    87472    88160
G0307     82024    82565    83088    84066    84585    85730    86654    87046    87475    88161
G0328     82030    82570    83090    84075    84586    85732    86658    87070    87476    88162
P3000     82040    82575    83150    84078    84588    85810    86663    87071    87477    88164
P3001     82042    82585    83491    84080    84590    85999    86664    87073    87480    88165
P7001     82043    82595    83497    84081    84591    86000    86665    87075    87481    88166
0026T     82044    82600    83498    84085    84597    86001    86666    87076    87482    88167
0030T     82045    82607    83499    84087    84600    86003    86668    87077    87485    88172
0041T     82055    82608    83500    84100    84620    86005    86671    87081    87486    88173
0103T     82085    82615    83505    84105    84630    86021    86674    87084    87487   
0111T     82088    82626    83516    84106    84681    86022    86677    87086    87490    88174
17311    82101    82627    83518    84110    84702    86023    86682    87088    87491    88175
17312    82103    82633    83519    84119    84703    86038    86684    87101    87492    88182
17313    82104    82634    83520    84120    84999    86039    86687    87102    87495    88184
17314    82105    82638    83525    84126    85002    86060    86688    87103    87496    88185
17315    82106    82646    83527    84127    85004    86063    86689    87106    87497    88187
78110    82107    82649    83528    84132    85007    86140    86692    87107    87498    88188
78111    82108    82651    83540    84133    85008    86141    86694    87109    87510    88189
78120    82120    82652    83550    84134    85009    86146    86695    87110    87511    88199
78121    82127    82654    83570    84135    85014    86147    86696    87116    87512    88230
78122    82128    82656    83582    84138    85018    86148    86698    87118    87515    88233
78130    82131    82657    83586    84140    85025    86155    86701    87140    87516    88235
78191    82135    82658    83593    84143    85027    86156    86702    87143    87517    88237
78270    82136    82664    83605    84144    85032    86157    86703    87147    87520    88239
78271    82139    82666    83615    84146    85041    86160    86704    87149    87521    88245
78272    82140    82668    83625    84150    85044    86161    86705    87152    87522    88248
80048    82143    82670    83630    84152    85045    86162    86706    87158    87525    88249
80050    82145    82671    83631    84153    85046    86171    86707    87164    87526    88261
80051    82150    82672    83632    84154    85048    86185    86708    87166    87527    88262
80053    82154    82677    83633    84155    85049    86200    86709    87168    87528    88263
80055    82157    82679    83634    84156    85055    86215    86710    87169    87529    88264
80061    82160    82690    83655    84157    85060    86225    86713    87172    87530    88267
80069    82163    82693    83661    84160    85097    86226    86717    87176    87531    88269
80074    82164    82696    83662    84163    85130    86235    86720    87177    87532    88271
80076    82172    82705    83663    84165    85170    86243    86723    87181    87533    88272
80100    82175    82710    83664    84166    85175    86255    86727    87184    87534    88273
80101    82180    82715    83670    84181    85210    86256    86729    87185    87535    88274
80102    82190    82725    83690    84182    85220    86277    86732    87186    87536    88275
80150    82205    82726    83695    84202    85230    86280    86735    87187    87537    88280
80152    82232    82728    83698    84203    85240    86294    86738    87188    87538    88283
80154    82239    82731    83700    84206    85244    86300    86741    87190    87539    88285
80156    82240    82735    83701    84207    85245    86301    86744    87197    87540    88289
80157    82247    82742    83704    84210    85246    86304    86747    87205    87541    88291
80158    82248    82746    83718    84220    85247    86308    86750    87206    87542    88299
80160    82252    82747    83719    84228    85250    86309    86753    87207    87550    88300
80162    82261    82757    83721    84233    85260    86310    86756    87209    87551    88302
80164    82271    82759    83727    84234    85270    86316    86757    87210    87552    88304
80166    82274    82760    83735    84235    85280    86317    86759    87220    87555    88305
80168    82286    82775    83775    84238    85290    86318    86762    87230    87556    88307
80170    82300    82776    83785    84244    85291    86320    86765    87250    87557    88309
80172    82306    82784    83788    84252    85292    86325    86768    87252    87560    88318
80173    82307    82785    83789    84255    85293    86327    86771    87253    87561    88319
80174    82308    82787    83805    84260    85300    86329    86774    87254    87562    88321
80176    82310    82800    83825    84270    85301    86331    86777    87255    87580    88323
80178    82330    82803    83835    84275    85302    86332    86778    87260    87581    88325
80182    82331    82805    83840    84285    85303    86334    86781    87265    87582    88331
80184    82340    82810    83857    84295    85305    86335    86784    87267    87590    88332
80185    82355    82820    83858    84300    85306    86336    86787    87269    87591    88333
80186    82360    82926    83864    84302    85307    86337    86788    87270    87592    88334
80188    82365    82928    83866    84305    85335    86340    86789    87271    87620    88342
80190    82370    82938    83872    84307    85337    86341    86790    87272    87621    88346
80192    82373    82941    83873    84311    85345    86343    86793    87273    87622    88347
80194    82374    82943    83874    84315    85347    86344    86800    87274    87640    88348
80195    82375    82945    83880    84375    85348    86353    86803    87275    87641    88349
80196    82376    82946    83883    84376    85360    86355    86804    87276    87650    88355
80197    82378    82947    83885    84377    85362    86357    86805    87277    87651    88356
80198    82379    82948    83887    84378    85366    86359    86806    87278    87652    88358
80200    82380    82950    83890    84379    85370    86360    86807    87279    87653    88360
80201    82382    82951    83891    84392    85378    86361    86808    87280    87660    88361
80202    82383    82952    83892    84402    85379    86367    86812    87281    87797    88362
80299    82384    82953    83893    84403    85380    86376    86813    87283    87798    88365
80400    82387    82955    83894    84425    85384    86378    86816    87285    87799    88367
80402    82390    82960    83896    84430    85385    86382    86817    87290    87800    88368
80406    82397    82963    83897    84432    85390    86384    86821    87299    87801    88371
80408    82415    82965    83898    84436    85396    86403    86822    87300    87802    88372
80410    82435    82975    83900    84437    85400    86406    86849    87301    87803    88380
80412    82436    82977    83901    84439    85410    86430    86850    87305    87804    88384
80414    82438    82978    83902    84442    85415    86431    86860    87320    87807    88385
80415    82441    82979    83903    84443    85420    86480    86870    87324    87808    88386
80416    82465    82980    83904    84445    85421    86590    86880    87327    87810    88399
80417    82480    82985    83905    84446    85441    86592    86885    87328    87850    89050
80418    82482    83001    83906    84449    85445    86593    86886    87329    87880    89051
80420    82485    83002    83907    84450    85460    86602    86890    87332    87899    89060
80422    82486    83003    83908    84460    85461    86603    86900    87335    87901    89125
80424    82487    83008    83909    84466    85475    86606    86901    87336    87902    89160
80426    82488    83009    83912    84478    85520    86609    86903    87337    87903    89225
80428    82489    83010    83913    84479    85525    86611    86904    87338    87904    89230
80430    82491    83012    83914    84480    85530    86612    86905    87339    87999    89235
80432    82492    83015    83915    84481    85536    86615    86906    87340    88104    89240
80434    82495    83018    83916    84482    85540    86617    86920    87341    88106    89300
80435    82507    83020    83918    84484    85547    86618    86921    87350    88107    89310
80436    82520    83021    83919    84485    85549    86619    86922    87380    88108    89320
80438    82523    83030    83921    84488    85555    86622    86940    87385    88112    89321
80439    82525    83033    83925    84490    85557    86625    86941    87390    88130    89325
80440    82528    83036    83930    84510    85576    86628    86970    87391    88140    89329
81003    82530    83045    83935    84512    85597    86631    86971    87400    88141    89330

Codes Excluded from CLIA Requirements

80103    84061    86580    86930    86985    88305    89049    89140
80500    86077    86586    86931    86999    88311    89100    89141
80502    86078    86891    86932    87900    88312    89105   
81050    86079    86910    86945    88125    88313    89130   
82075    86485    86911    86950    88240    88314    89132   
83013    86490    86923    86960    88241    88329    89135   
83014    86510    86927    86965    88304    88400    89136   

CPT that requires Certificate for Provider-Performed Microscopy Procedures (PPMP)

CPT codes for PAP Tests

HCPCS Codes for Screening Pap Tests

G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

G0143 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision

G0144 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system under physician supervision

G0145 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

G0147 Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

G0148 Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening

Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision

HCPCS Codes for Physician’s Interpretation of Screening Pap Tests

G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician

Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician

P3001 Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician

HCPCS Code for Laboratory Specimen of Screening Pap Tests

Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

NOTE: In those situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical laboratories unable to interpret the test results, another specimen may be collected. To bill for this reconveyance, annotate the claim with HCPCS code Q0091 along with modifier -76 (repeat procedure or service by same physician or other qualified health care professional).

Diagnosis Codes for Low Risk Screening Pap Tests

V72.31 Routine gynecological examination NOTE: This diagnosis should only be used when the provider performs  a full gynecological examination.

Special screening for malignant neoplasms, cervix

V76.47 Special screening for malignant neoplasms, other sites, vagina

V76.49 Special screening for malignant neoplasms, other sites NOTE:  Providers use this diagnosis for women without a cervix.

Diagnosis Code for High Risk Screening Pap Tests

V15.89 Other specified personal history presenting hazards to health, other

Coverage Information

The Medicare-covered screening Pap test (Pap smear) is a laboratory test that consists of a routine exfoliative cytology test (Papanicolaou test) for early detection of cervical cancer. It includes collection of a sample of cervical cells and a physician’s interpretation of the test results.

Medicare covers a screening Pap test for all female beneficiaries when a physician (or authorized practitioner) orders the test.

Risk Factors

For purposes of this benefit, high risk categories for cervical and vaginal cancer include:

Early onset of sexual activity (under 16 years of age),

Multiple sexual partners (five or more in a lifetime),

History of a sexually transmitted infection (STI) (including human immunodeficiency virus [HIV] infection),

Fewer than three negative Pap tests or no Pap tests within the previous 7 years, and

DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy.


Covered Once Every 24 Months

Medicare Part B covers a screening Pap test for all asymptomatic female beneficiaries every 24 months (i.e., at least 23 months after the most recent screening Pap test).

Covered Once Every 12 Months

Medicare Part B covers an annual screening Pap test (i.e., at least 11 months after the most recent screening Pap test) for female beneficiaries who meet at least one of the following criteria:

Evidence (on the basis of her medical history or other findings) that she is at high risk (high risk categories described above) for developing cervical or vaginal cancer and her physician (or authorized practitioner) recommends that she have the test more frequently than every two years,

A woman of childbearing age who has had a pap test during any of the preceding 3 years that indicated the presence of cervical or vaginal cancer or other abnormality. A “woman of childbearing age” is one who is premenopausal and has been determined by a physician or qualified practitioner to be of childbearing age based on the medical history or other findings.

When calculating frequency to determine the annual period, 11 months must elapse following the month in which the last screening Pap test took place. Follow the same procedure to calculate frequency for the 23-month period.

EXAMPLE: A beneficiary in a high risk category gets a screening Pap test in January 2012. The count starts February 2012. The beneficiary may get another screening Pap test in January 2013.

Coinsurance or Copayment and Deductible

The beneficiary pays nothing (no coinsurance or copayment and no Medicare Part B deductible) for the screening Pap test if the provider accepts assignment. Financial responsibilities may apply for the beneficiary if the provider does not accept assignment.

For more information https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-Pap-Tests-Booklet-ICN907791.pdf

What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It is the most widely used set of performance measures in the managed care industry. HEDIS was developed, and is maintained, by the National Committee for Quality Assurance (NCQA).

HEDIS has become more than a set of performance measures; it is part of an integrated system to establish accountability in managed care.

HEDIS reporting is mandated by NCQA for compliance and accreditation. It is important that health care providers and their staff members become familiar with HEDIS to understand what health plans are required to report to help improve the quality of care provided to patients.

HEDIS is a multipurpose tool originally designed to address private employers’ needs and has been adopted by public purchasers, regulators and consumers. Quality improvement activities, health management systems and provider profiling efforts all have used HEDIS as a core measurement. HEDIS is a part of purchaser requests, an element of NCQA accreditation and the basis of a consumer report card for managed care. HEDIS data are collected through a combination of surveys, provider medical chart reviews and insurance claims/encounter data.

To ensure the validity of HEDIS results, all data are rigorously audited by certified auditors using a process designed by NCQA. Consumers benefit from HEDIS data through the State of Health Care Quality report, a comprehensive look at the performance of the nation's health care system. HEDIS data also are the centerpiece of most health plan "report cards" that appear in national magazines and local newspapers.

Data collection begins with queries of the claims/encounter data. If the encounter data do not contain evidence of the required visit, test or prescription during the specified time frame, then the health plan staff must review the member's medical record to determine if care was provided. For some measures, data are collected only from claims/encounters, and medical record reviewers do no validation of the care. 

Health care providers can improve HEDIS scores significantly by submitting accurately coded claims/encounters data for each service rendered, and by keeping accurate, legible and complete medical records for their patients. Chart documentation must reflect services billed. Claims/encounters data are the most efficient method to report HEDIS, which helps ensure medical chart reviews and reviewer visits to providers are kept to a minimum.

HEDIS 2011 contains 75 measures across eight domains of care, which are as follows:

Effectiveness of care, i.e., immunizations, cancer screenings, diabetes care, weight assessment, appropriate treatment for acute and chronic illnesses, etc.

Access/availability of care

Satisfaction with experience of care (member satisfaction surveys)

Health plan stability

Use of services, i.e., frequency of selected procedures, well-child visits

Cost of care

Informed health care choices

Health plan descriptive information

Actions health care providers can take: 

Submit appropriately coded claims/encounters data for each service rendered in a timely manner

Submit encounters electronically and work reject reports completely 

Provide lab data as requested

Keep accurate, legible and complete medical records for their patients

Help ensure HEDIS-related preventive screenings, tests and vaccines are performed timely and in an appropriate manner

Allow access to or provide records as requested (online capability)

Also see 'CAHPS' and 'HOS'

What is CAHPS?

The National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) require health plans to conduct a member satisfaction survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Results are produced annually and compared with national benchmarks. The surveys are administered in early spring by mail, with telephonic follow-up for nonresponders; results are available in late summer for commercial and Medicaid health plans and later in the year for Medicare.

CAHPS is a member survey that gauges satisfaction with services provided by the health plan and member perception of provider accessibility, patient-physician relationship and provider communication. The survey has approximately 70 questions; results are reported in composites and overall ratings.

There are several questions relating to member satisfaction with physicians. These may be of interest, as they pertain to the patient-physician relationship and may provide improvement opportunities in everyday practice, such as:

Shared Decision-making (commercial measure): Measures the patients’ experiences with physicians in discussing pros and cons of treatment and asking what was best for the patients

Health promotion and education (commercial measure): Measures the patients’ experience with physicians in discussing ways to prevent illnesses

Coordination of care (commercial measure): Measures the patients’ perceptions of the personal physicians’ knowledge and if the personal physicians were up-to-date about the care their patients received from other health care providers 

How well physicians communicate (commercial, Medicaid and Medicare measure): Measures the patients’ experiences with whether the physicians listened, explained, spent time with the patients and respected what the patients had to say 

Getting care quickly (commercial, Medicaid and Medicare measure): Measures the experiences the patients had in receiving care or advice in a reasonable time, including time spent in the offices waiting rooms

Getting needed care (commercial, Medicaid and Medicare measure): Measures the experiences the patients had when attempting to get care or services from physicians, specialists, including treatments or tests  

Rating of health care (commercial, Medicaid and Medicare measure): This survey item gives patients an opportunity to rate all the health care they have received in the last six to12  months

Rating of personal physician (commercial, Medicaid and Medicare measure): This survey item asks the patients to rate their primary physicians’ performance over the last six to 12 months

Rating of specialist (commercial, Medicaid and Medicare measure): This rating measures patients’ experiences with specialists over the last six to 12 months

Rating of health plan (commercial, Medicaid and Medicare measure): This rating measures the patients’ overall experiences with their health plans over the last six to 12 months

The CAHPS survey also contains effectiveness of care measures. Members are asked about whether they received flu/pneumonia shots, direction from their physicians on aspirin usage and if their physicians discussed tobacco cessation.

Actions physicians can take:

Communicate to patients thoroughly, completely and in a manner they understand

Specialists should communicate to patients’ primary physicians on status, tests, medications, outcomes, etc.

Submit referrals and obtain authorizations as appropriate

Facilitate appointments, schedule for urgent cases and limit patient wait times

Be aware of the time patients wait 

Listen to patients and make sure they understand orders and communications

Encourage preventive measures, such as influenza and pneumococcal vaccines

Also see 'HEDIS' and 'HOS'

What is HOS?

The Health Outcomes Survey (HOS) is a Centers for Medicare & Medicaid Services (CMS) survey that gathers meaningful health status data from people with Medicare. Like HEDIS and CAHPS, HOS is part of an integrated system for use in quality improvement activities and to establish accountability in managed care. All managed care plans with Medicare Advantage (MA) contracts, including Humana, must participate. 

A random sample of Medicare beneficiaries receive a baseline survey in the spring. Two years later, the same respondents are surveyed for follow-up measurement. Survey completion is voluntary. The difference in the scores for the two-year period shows if a member’s physical and mental health status is categorized as better, the same or worse than expected. Member responses are shared with Humana for use in quality improvement initiatives.  

HOS may be of interest to physicians as they could receive questions about the survey from their Medicare patients. Survey questions pertain to patient-physician relationships and help identify areas for improving member health outcomes. Members are asked questions about overall physical and mental health status. They also are asked if they had a discussion about or received counseling or intervention from their physician on the following topics:

Management of urinary incontinence 

Physical activity in older adults

Management of the risk of falls

Osteoporosis testing in older women

Actions physicians can take:

Understand that the survey is a patient-based, self-reported survey with questions about overall physical and mental health status

Discuss and provide counseling and/or interventions as needed for urinary incontinence, physical activity, risk for falls and osteoporosis testing 

Also see 'HEDIS' and 'CAHPS'

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