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Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

by Shannon Newell, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer

If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called ‘SHFFT’ (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:

  • Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
  • Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)


MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.

Model overview

The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.

This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.


Cost outcomes

CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished ‘target price.’

CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.

If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.

Quality-adjusted target price

To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.

The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:

  • Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measure is the HCAHPS survey.
  • Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
  • THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.


Hospital (accountable party), collaborators, and Advanced Payment Models

The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.

CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.

The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.


CDI program opportunities

There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:

  • Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
  • Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
  • Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.

The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.

  • Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
  • Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.

The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.



Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.

As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.

Additional information on the proposed rule can be located at



Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or – HIM Briefings

20 Best From Home Top Medical Coding Schools and Programs

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Training for at-home medical coding jobs can be completed wholly online for the greatest flexibility and career-life balance. Whether you’re a parent, disabled, retired, a military spouse, or simply attracted to working in the comfort of home, medical coding is a hot job. CNBC reported that medical coding has a prescription for fast growth since healthcare facilities have switched to electronic records. The BLS predicts that medical records management will spark 29,000 new positions for a 15 percent hiring increase. Companies like Humana, Maxim Health, and Aviacode need fresh telecommuting talent, so consider these 20 Best From Home Top Medical Coding Schools and Programs.

Our ranking zeros in on top online medical coding programs that fulfill requirements for certification, such as Certified Coding Associate (CCA). That’s because pay climbs for credentials with an average salary of $ 47,796 per year. We used the NCES College Navigator tool to search for coding schools with distance education. Each prospective program had to be regionally accredited, uphold AHIMA standards, feature at least four courses, and include virtual practicum. Preference was given to colleges holding national or regional rankings for prestige. From home coding curricula was also judged for affordability, class size, placement, credit transfer, and academic rigor.

1. Drexel University

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Located in Philadelphia’s Powelton Village, Drexel University is a private, nonprofit research hub with cooperative education for over 26,300 Dragons. According to the U.S. News, Drexel is the 96th best national university, 65th top value, and 14th most innovative school. The College of Nursing and Health Professions confers an online, six-course Certificate in Medical Billing and Coding.

Tuition Total: $ 14,364

Learn more about From Home Top Medical Coding Schools and Programs at Drexel University here.

2. University of Utah

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Affiliated with 22 Rhodes Scholars, the University of Utah is a public, space-grant RU/VH institution selectively admitting 31,500 Utes in Salt Lake City and online. The U.S. News named Utah the 111th best university and 73rd best for vets school. There’s a three-part Professional Medical Coding and Billing program delivered online with real-world 3M encoding software.

Tuition Total: $ 3,495

Learn more about From Home Top Medical Coding Schools and Programs at the University of Utah here.

3. Indiana University – Purdue University Indianapolis

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Endowed for $ 601 million, Indiana University-Purdue University Indianapolis is a public, co-educational RU/H institution “Fulfilling the Promise” to over 30,100 Jaguars. The U.S. News ranked IUPUI as America’s 197th best university and 106th top public college. Online learners can pursue the 26-credit Medical Coding Certificate through the School of Informatics and Computing for AHIMA credentialing.

Tuition Total: $ 9,233

Learn more about From Home Top Medical Coding Schools and Programs at Indiana University – Purdue University Indianapolis here.

4. Keiser University

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Belonging to the NAIA Sun Conference, Keiser University is a private, nonprofit SACS-accredited college serving over 16,300 Seahawks in Fort Lauderdale and beyond. Keiser is the South’s 23rd top school and 11th best value according to the U.S. News. Online students can prepare for the AAPC exam in the two-year Associate of Science in Medical Administrative Billing and Coding.

Tuition Total: $ 37,728

Learn more about From Home Top Medical Coding Schools and Programs at Keiser University here.

5. Albany State University

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Established in 1874 for freed slaves, Albany State University is a public, TMCF-member institution with over 7,100 Golden Rams studying in southwest Georgia and online. The U.S. News lauded Albany State as the 32nd best historically black school nationwide. The 22-credit Online Certificate in Medical Coding builds expertise in ICD-10 coding systems from home.

Tuition Total: $ 2,860

Learn more about From Home Top Medical Coding Schools and Programs at Albany State University here.

6. Weber State University

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Attracting 26,600 Wildcats to 250+ academic programs, Weber State University is located in Ogden, Utah, with NWCCU accreditation for public, liberal arts education. The U.S. News crowned Weber the West’s 76th top regional university. The Dumke College of Health Professions confers a 10-course Certificate of Proficiency in Healthcare Coding online for a median salary of $ 34,000.

Tuition Total: $ 5,340

Learn more about From Home Top Medical Coding Schools and Programs at Weber State University here.

7. Florida A&M University

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Classified as a public, land-grant RU/H doctoral institution, Florida A&M University is endowed for $ 127.18 million to educate over 9,600 Rattlers from Tallahassee and beyond. High school counselors surveyed by the U.S. News placed FAMU 173rd nationally. The School of Allied Health Sciences follows AHIMA standards for an online, nine-course Medical Coding Certificate Program.

Tuition Total: $ 7,965

Learn more about From Home Top Medical Coding Schoools and Programs at Florida A&M University here.

8. Great Falls College Montana State University

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Founded in 1969 for “Changing Lives, Achieving Dreams,” Great Falls College MSU is a two-year, public teaching institution enrolling over 4,700 students in Montana and online. Great Falls is affiliated with the U.S. News’ 210th best university and 118th top public school. Students can pursue the 63-credit A.A.S. in Medical Billing and Coding Specialist online.

Tuition Total: $ 8,374

Learn more about From Top Home Medical Coding Schools and Programs at Great Falls College Montana State University here.

9. Herzing University

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Operating 11 campuses and an online division from Milwaukee, Herzing University is a private, nonprofit Highter Learning Commission and a Member of the North Central Association accredited institution enrolling over 330 adult learners. The U.S. News applauded Herzing for America’s 142nd best online undergraduate programs. In 12 months, online students can complete the 44-credit Diploma in Medical Insurance Billing and Coding Specialist for CCSA Associate certification. For more information regarding graduation rates, median student debt for students who have completed the program, and other information, to Herzing’s consumer disclosure website.

Tuition Total: $ 12,560

Learn more about From Home Top Medical Coding Schools and Programs at Herzing University here.

10. Peirce College

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Led by President James J. Mergiotti, Peirce College is a private, nonprofit MSCHE-accredited college based on Philadelphia’s Pine Street to educate over 1,200. Peirce is acclaimed for holding America’s 132nd best online undergraduate degrees by the U.S. News. The Allied Health Division offers a 39-credit, competency-based Certificate in Medical Coding online with a virtual practice workshop.

Tuition Total: $ 17,040

Learn more about From Home Top Medical Coding Schools and Programs at Peirce College here.

11. SUNY Herkimer College

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Celebrating its 50th anniversary, SUNY Herkimer College is a two-year, public lower-division institution registering over 3,300 Generals in Upstate New York near Utica. Herkimer was picked for the prestigious 2017 Aspen Prize for Community College Excellence. Home-based learners could finish the 12-month Online Medical Coding-Transcriptionist Certificate via the Internet Academy for mastering ICD-9-CM, CPT, and HCPCS codes.

Tuition Total: $ 4,490

Learn more about From Home Top Medical Coding Schools and Programs at SUNY Herkimer College here.

12. Great Basin College

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Governed by the Nevada System of Higher Education, Great Basin College is a public, two-year career-oriented institution with NWCCU accreditation to educate over 3,400 in Elko, Ely, Battle Mountain, and online. Niche placed Great Basin as America’s 116th “Best Online College.” Each Fall, online students begin the two-semester Certificate of Achievement in Professional Medical Coding and Billing.

Tuition Total: $ 3,060

Learn more about From Home Top Medical Coding Schools and Programs at Great Basin College here.

13. The University of Cincinnati Clermont College

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Sitting on 91.2 wood cares in Batavia, Ohio, UC Clermont College is a regional public, two-year satellite of the University of Cincinnati with over 3,700 Cougars finding “Strength in Unity.” The U.S. News placed UC as America’s 135th best university and 64th top public college. Clermont offers an 11-course Online Certificate in Medical Biller/Coder with open admission.

Tuition Total: $ 7,320

Learn more about From Home Top Medical Coding Schools and Programs at The University of Cincinnati Clermont College here.

14. Kaplan University

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Training 37,000 non-traditional students, Kaplan University is a primarily online private, for-profit HLC-accredited institution of Graham Holdings Company in Davenport, Iowa, with 14 national campuses. The U.S. News declared Kaplan’s online undergraduate programs as the 156th best nationwide. Students work from home for the 39-credit Online Medical Billing and Coding Certificate or 57-credit Online Medical Office Administration Certificate.

Tuition Total: $ 14,469

Learn more about From Home Top Medical Coding Schools and Programs at Kaplan University here

15. Central Texas College

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Since opening in 1965 for Bell County citizens, Central Texas College has expanded as a public, two-year SACS-accredited school with over 39,200 Eagles in Killeen and online. In Community College Week. CTC ranked 15th among associate degree producers nationally. AAPC qualifications can be fulfilled with the 39-credit Online Certificate of Completion in Medical Coding & Billing.

Tuition Total: $ 8,775

Learn more about From Home Top Medical Coding Schools and Programs at Central Texas College here.

16. Sullivan University

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As the SACS’ first accredited private, for-profit school, Sullivan University serves over 6,000 students from in Louisville, Lexington, Fort Knox, and online. Niche recognized Sullivan as America’s 64th “Best Online College” and 157th “Best College Campus.” The College of Health Sciences awards a 47-credit, 12-month Medical Coding Diploma online with courses like information literacy, human anatomy, and CCA review.

Tuition Total: $ 18,565

Learn more about From Home Top Medical Coding Schools and Programs at Sullivan University here.

17. Minnesota State College Southeast

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Accredited by the HLC-NCA, Minnesota State College Southeast is a public, two-year technical institution headquartered in Winona since 1949 to train over 2,700 professionals. Niche ranked MSC Southeast as America’s 42nd “Best Trade School.” Through D2L Brightspace, online students can attain the 46-credit Medical Coding Specialist Diploma or finish the 57-credit Medical Coding Specialist A.A.S.

Tuition Total: $ 8,644

Learn more about From Home Top Medical Coding Schools and Programs at Minnesota State Colleg Southeast here.

18. Bellevue College

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With Washington State’s third-largest enrollment at 37,000 Bulldogs, Bellevue College stands on King County’s Eastside as a public, open-access technical institution. PayScale recognized Bellevue for the 25th highest community college ROI with a median mid-career salary of $ 63,400. Online students can undertake the four-month, AHIMA-approved Professional Medical Coding and Billing Program with CareerStep for CPC credentialing.

Tuition Total: $ 2,995

Learn more about From Home Top Medical Coding Schools and Programs at Bellevue College here.

19. Mercy College of Ohio

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Opened by the Sisters of Mercy in 1917, Mercy College of Ohio is a private, bachelor’s-level health sciences institution with HLC-NCA accreditation to educate over 1,200 future practitioners. College Values Online included Mercy among the “50 Most Affordable Small Catholic Colleges” nationwide. Attend the Virtual Open House to consider the 26-credit Online Medical Coding Certificate Program.

Tuition Total: $ 11,600

Learn more about From Home Top Medical Coding Schools and Programs at Mercy College of Ohio here.

20. National American University

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Given HLC-NCA accreditation in 1985, National American University is a private, for-profit learning system based in Rapid City, South Dakota, that’s educating over 7,900 students at 33 U.S. locations and online. College Factual ranked NAU in the top 5 percent nationally for ethnic diversity. The College of Health and Sciences confers a 12-month Healthcare Coding Diploma adhered to AHIMA standards.

Tuition Total: $ 13,212

Learn more about From Home Top Medical Coding Schools and Programs at National American University here.

Top Medical Coding Schools

Is this realy significant same day?


I could be missing something (please feel free to let me know)
This is an account from urgent care

A Person came in for a tick bite:

S40861A as admitting and principle (bite right upper arm initial encounter)
W57XXXA secondary bitten arthropod-ext. cause.

I coded the retained organic fragments Z1839

Additionally I coded a procedure for removal of a foreign body 10120 incision and removal of foreign body-simple. That’s it just the procedure.

The physician just sent off a Lyme AB to the lab instead of doing the Lyme prophylaxis because the person had antibiotic allergies.

I did NOT code a professional E/M with a modifier 25, and was questioned about this.
The patient was here for a tick bite, they decided to remove the reminants of the tick.
Sent blood for a Lyme AB.

We also code for the tech. side-so the blood sent to the lab is covered on our facility side.
Am I missing something here? I’m not seeing anything else that was treated/assessed beyond the person coming in for a tick bite, there’s nothing more that warrants a separate E/M with a modifier 25.

OR did I miss something right in front of my face?

Medical Billing and Coding Forum – Modifiers

Interstate Medical Licensure Compact Commission proposes licensure process


The medical licensing tool aimed at expediting the process through which physicians can obtain licenses to practice in multiple states is one step closer to becoming a reality as more details of the process come into focus. Once it’s up and running, the Interstate Medical Licensure Compact will allow physicians licensed in one participating state to gain licensure in other participating states without having to repeat the entire licensing process in each state.

The Interstate Medical Licensure Compact Commission, which is responsible for the compact’s governing rules and administration, recently released a proposed process for expedited licensure through the compact and opened the period for public comments. The commission will consider the proposed rule at its meeting in early October.


The expedited licensure process

The basic process is the same as the one outlined in model legislation released two years ago, says Ian Marquand, chair of the Interstate Medical Licensure Compact Commission. Under the newly proposed process, a physician applies for expedited licensure via the compact through the state where he or she claims principal licensure. The state of principal licensure is where the physician resides, practices, is employed, or files a federal tax return.

"The physician will have to provide some information so that we can make sure that state is legitimately the state of principal license. A physician can’t willy-nilly pick a state in the compact," Marquand says. The applying physician will also have to pay the commission a service fee and submit to a criminal background check through a law enforcement agency, including providing fingerprints or other biometric data.

"There are no heavy applications at this point. The point of this is to make it much easier for a physician to get licensed in additional states and for much less time and energy expended," he says.

The principal licensure state would then review the applicant’s qualifications to determine if he or she is eligible for expedited licensure, perform a criminal background check, and issue a letter to the applicant and the compact commission verifying or denying the physician’s eligibility. Once the applicant receives that letter, he or she can then select from which member states to request expedited licensure and pay those states’ licensure fees. The relevant member boards would then issue full and unrestricted licenses to the applicant. Those licenses would be valid for as long as any other full and unrestricted license normally issued by that state board.


Application turnaround time

There is not a set amount of time to process the application for licensure through the compact due to several variables, Marquand says. These variables include how quickly the physician goes to a law enforcement agency to get fingerprinted, the amount of time necessary to complete the criminal background check and deliver the results to the medical board at the state of principal licensure, and how long it takes that state of principal licensure to review the criminal background check and the applicant’s other details (e.g., board certification and medical education).

A few test runs of the process have been performed in Marquand’s home state of Montana. "We find that it only really takes a matter of hours but it’s not the only thing our people have to do. So where it falls in the queue depends on how long it’s going to take for our people to actually get to do the work. That’s a variable. The communication between a state of principal license to compact commission and then compact commission to receiving state, I don’t think those should take very long at all."

In contrast, the applicant’s responsiveness will be a factor in the turnaround time. Marquand provides a hypothetical scenario to illustrate this point: Dr. Smith, whose state of principal licensure is Montana, applies for licensure in three additional states through the commission. He is prompt about providing his fingerprints and submitting to the criminal background check, which allows the staff in Montana to process his application fairly quickly. In a matter of days Dr. Smith is certified by the commission but then puts off paying the licensure fees.

"We can’t do anything until the fees have been paid. So if the physician is slow about paying fees, that’s on them, not on us," Marquand says. "But once the fees are paid and delivered to the receiving states, we don’t expect [the states] to take very long in issuing the license."

To help motivate physicians to stay on track with their applications, the proposed rule sets a 60-day limit for the applicant to submit all requested materials.

"With every application in the professional licensing world, there’s an expiration date on the application. It doesn’t sit there forever waiting for you to finish. If you don’t get it done, it expires. Putting a 60-day limit on that seems pretty reasonable to me," he says.

Returning to the example of Dr. Smith, Marquand says if the physician applies through the compact commission, pays the initial processing fee but then doesn’t have his fingerprints taken and is unresponsive to the commission’s requests for information for more than 60 days, the application is withdrawn.

"It put some onus on the physician to take some action. But will it take 60 days for processing? No, that’s just the time we give the physician to get any information that we need. But I can’t imagine that happening very often, if at all." Marquand says.

Once a physician is certified through the commission, that certification is valid for one year. This means that if Dr. Smith initially selects one compact state for licensure, such as Wyoming, and then decides six months later that he wants a license for Idaho as well, he will not have to reapply, Marquand says. Dr. Smith will simply need to inform his state of principal licensure?Montana?that he’d like to practice Idaho. The board in Montana will notify the commission and then Idaho will issue the license fairly quickly.

"The only thing that would preclude that would be if Dr. Smith gets in trouble with either the Montana or the Wyoming board and his license is suspended. Then his compact eligibility goes out the window," he says.

When a physician’s license is suspended, it is the responsibility of the member state in which the disciplinary action occurred to notify the commission, which in turn, would notify all the states in the compact. At that point, it would be up to each individual state to decide what to do.

"It’s presumed that reciprocal discipline will happen very quickly. So if Dr. Smith gets in trouble in Wyoming, Wyoming reports him to the commission and Montana would probably take very swift action to suspend his license there, Marquand says. "And if he’s licensed anywhere else in the compact, those states would have the option of doing the same. We want to at least make it possible for very swift action in all the states.

He adds that there are circumstances where reciprocal discipline is automatic, such as when a license from a state of principal licensure is revoked, suspended, or surrendered. In such cases, states can change that automatic action to something else, if they choose. So while states would have some discretion, it may come after an initial action.

Physicians who retain clean records and maintain their qualifications would be able to obtain licenses in as many compact states as they want within a year of achieving certification from the commission, as long as they’re willing to pay the fees.


Work to be done

Some details of this process have yet to be finalized. For example, the amount of the commission’s processing fee has yet to be determined. The commission will likely take up this issue by the end of the year.

"Each individual state within the compact also needs to have its own discussion of whether it wants to charge an application fee to cover the cost of reviewing the physician’s qualifications," Marquand says. In Montana there is a proposal put forth for a $ 100 fee. That proposal still needs to go through a public comment period and receive final approval from the state medical board.

After considering the provisions of the proposed rule, the commission will have several options: Adopt the rule as-is, adopt it with amendments, send it back to the committee for more work, or scrap it completely.

"I’m certainly optimistic that the commission will adopt these. And whether there are any changes suggested to them through comments, we’ll deal with them. I think the commission is anxious to get these rules in place and move on to the next topic," Marquand says.

If the commission decides that the proposal requires significant changes, the rule could be brought back to the commission as early as December.

Work on the application portal for expedited licensure is also underway but an open date has not been announced, Marquand says. However, the commission has set January 2017 as the target date for the first licenses to be issued by a member state using the compact process.

To assist with all the work that remains to be done, the U.S. Health Resources and Services Administration (HRSA) recently announced a $ 250,000 annual grant for three years to help the commission get up and running. The grant, which was requested by the Federation of State Medical Board, underwrites the cost of the commission.

"That takes a huge load off on us as commissioners. We know that through that grant there will be money available to cover technical costs, meeting costs, and maybe even staff costs for the next three years," Marquand says. He forecasts that after the three years, the commission should be able to stand on its own financially and operate on the service fees it collects.



Often the Interstate Medical Licensure Compact is discussed in the same breath as telemedicine but Marquand emphasizes the distinction between the two. The compact relates exclusively to licensing and therefore does not provide any rules, regulations, or even any guidelines on the use of telemedicine. Although physicians or health organizations may want to use it to allow their own practice or corporate practice to expand into more states, they will still need to follow the regulations of those states once licensed.

"I understand that there may be benefits of the compact for physicians who want to do telemedicine in more places, but that’s not specifically why the compact exists. The compact exists for licensed physicians to get licenses in other states quickly and efficiently, regardless of what kind of practice they want to do," Marquand says.

He recalls this topic came up at a press event in Washington, D.C., designed to promote the compact to members of Congress and major healthcare organizations. When the question was posed of who would be the major user of the compact?large healthcare organizations that want to use telemedicine, or individual physicians who want to expand a practice across state lines either in person or by telemedicine?the answer that came back was it would likely be both.

"Here’s how I look at this: Think of two parallel highways. On one, there are physicians using telemedicine. The compact is on the other, with ramps between them," he explains. "The folks on the telemedicine highway may take a ramp over to the compact highway to get additional licensure, but then they’ll get back on the telemedicine highway."


Moving forward

As this issue of CPRLI went to print, 17 states have enacted compact legislation and nine others have introduced it. Marquand is optimistic more will adopt legislation.

"There are a couple that haven’t quite got to the finish line and we understand there are going to be states that are on the sidelines, waiting to see what the commission does and see how the compact really works," he says.

That’s why Marquand says the work the commission is doing to get the compact up and running is so important. The successful operation of the compact will be the commission’s biggest promotional tool for convincing additional states to participate. The hope is to bolster the case for joining once the commission has concrete figures on time frames and the number of licenses issued. – Credentialing and Peer Review Legal Insider

Physician casting for custom orthotics

We have a physician who is a foot and ankle specialist. He has been sending patient’s to our therapy department for casting molds for custom orthotics. He wants to start doing the casting himself in clinic. Would 97760 be the appropriate code for this or is there a better code?
Thanks in advance for any input!

Sally Cookman, CPC, COSC

Medical Billing and Coding Forum – Podiatry

What Are The Best Medical Billing and Coding Programs Online?

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Medical coding and billing is one of the few well-paid, in-demand healthcare jobs requiring solely a post-secondary certificate or associate degree at most. Good Financial Cents listed medical coder as the 20th “Best Job without a College Degree,” providing an average certified salary of $ 46,800. Online education is ideal for this digital IT profession that’s focused on the accurate organization of electronic health records. Online courses can train medical coding and billing staff to translate patients’ diagnoses and procedures into alphanumeric codes to file health insurance claims. As the health informatics field expands faster-than-average by 15 percent, the availability of online medical coding and billing options is becoming staggering. In this article, we’ll help point you to six of the best online colleges for tomorrow’s medical IT staff.

Herzing University

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Headquartered in Menomonee Falls, Wisconsin, Herzing University is a private, nonprofit HLC-accredited training institute that’s seen enrollment skyrocket by 260 percent since 2001. The U.S. News recognized Herzing for delivering America’s 142nd best online undergrad programs for $ 550 per credit hour. Adhering to the CAHIIM Academic Competencies, Herzing offers a 44-credit Diploma in Insurance Billing and Coding Specialist online over 12 months. Online courses like diagnosis coding and pathophysiology lead to a four-credit internship or research project and CCSA certification. Herzing undergraduates could also pursue the 61-credit A.A.S. Insurance Billing and Coding or 124-credit B.S. in Health Information Management.

Learn more about the Medical Billing and Coding Programs Online at Herzing University here.

Indiana University

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Endowed for $ 1.57 billion, Indiana University is a public, nine-campus teaching system in the APLU that’s regionally accredited to educate around 89,170 undergrad Hoosiers total. Graded America’s 27th “Top Public University” on Niche, IU offers the 54th best online undergraduate programs according to the U.S. News. The School of Informatics and Computing places CCA certification in reach for online learners with the 32-week Medical Coding Certificate. Full- or part-time students join each Fall to audit inpatient and outpatient health records. After the culminating, four-credit coding practicum, students can advance into the B.S. in Informatics – HealthCare Information Technology.

Learn more about the Medical Billing and Coding Programs Online at Indiana University here.

Keiser University

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Called the Keiser Institute of Technology until 1986, Keiser University is a private, nonprofit and nonsectarian SACS-accredited institution in Fort Lauderdale that’s educating nearly 18,000 Seahawks at an average net price of $ 21,129. Deemed America’s 30th “Best Online College” on Niche, Keiser is ranked the South’s 11th top value by the U.S. News. Distance learners could obtain the A.S. in Medical Administrative Billing & Coding, which meets CAHIIM standards. Conducted in English or Español, the 60-credit program features online courses from CPT-4 coding to medical ethics before an externship. Coders also have 100 percent job placement after the A.S. in Health Information Management.

Learn more about the Medical Billing and Coding Programs Online at Keiser University here.

Hunter College


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As a public, co-educational CUNY constituent, Hunter College is located on Manhattan’s Upper East Side near Lenox Hill to educate over 15,500 undergrad Hawks on a $ 99 million endowment. Ranked America’s 86th “Most Liberal College” on Niche, Hunter is the North’s 11th top public university according to the U.S. News. For $ 4,300 total, students can pursue the five-course Medical Coding & Billing Certificate in 80 hours online. Hunter also as a Combined Certificate in Outpatient and Inpatient Medical Billing for $ 5,300. Students progress through online modules like medical terminology and ICD-10 coding for CPC credentialing with exam discounts.

Learn more about Medical Billing and Coding Programs at Hunter College here.

St. Petersburg College


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Holding SACS and CAHIIM accreditation, St. Petersburg College is a public, four-year member of the Florida College System founded in 1927 that’s serving around 65,000 undergrads from Seminole to Clearwater and online. Crowned America’s 105th “Best Online College” on Niche, SPC ranked among Community College Week’s top 100 associate degree producers. Online learners could prepare for the CCA exam by completing the 37-credit Medical Coder Certificate and its two professional practica. Credits transfer seamlessly into the 70-credit Online Health Information Technology A.S. program, which has a 100 percent RHIT pass rate. There’s even a Health Data Management Advanced Technical Certificate.

Learn more about Medical Billing and Coding Programs at St. Petersburg College here.

Pace University

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Attracting around 12,700 Setters from all 50 states, Pace University is a private, nonsectarian ECAC institution tracing back to 1906 that’s located in Lower Manhattan with extensions in Pleasantville and online. Chosen as America’s 51st “Most Diverse College” on Niche, Pace is recognized by the U.S. News for the 36th best online undergrad offerings. Online students develop their e-portfolio with the asynchronous, nine-month Medical Billing & Coding Certificate program. Registering for the $ 3,995 program allows high school graduates to qualify for five certifications, including CCS and CPC-P. For taking the CEHRS exam, choose Pace’s seven-month Online Electronic Medical Records Specialist Certificate.
Learn more about Medical Billing and Coding Programs at Pace University here.

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Separating the good online medical coding and billing programs from the bad isn’t too difficult. Make certain you place accreditation, whether regional or national, at the top of your list to avoid registering at unaccredited diploma mills. Other important factors to search for are CPC certification rates, job placement, financial aid, awards or rankings, online technology, and curricular flexibility. Some honorable mentions to our above list include St. Catherine University, Drexel University, Central Texas College, Kaplan University, and Trident Technical College. The AAPC also offers online medical coding courses that cost members just $ 2,195 total for mastering ICD-10 classification.

Related Links

The 20 Best Medical Coding and Billing Programs Online

Top Medical Coding Schools

Global FESS


I have been given the ENT clinic as an auditing responsibility. Please help me understand if certain separate procedures are part of the global package. The patient had a Functional Endoscopic Sinus Surgery and presents 1 week postop. The physician performs a nasal endoscopy to help remove crusting from all patent sinuses. My feeling is that this procedure should be included during the postop period. The diagnosis used is nasal congestion.
This procedure 31231 and 92511 appear to be used quite frequently and would like to get a better handle on when this can be billed.
Please opine.

Medical Billing and Coding Forum – ENT/Otolaryngology

Making a checklist to prepare for the OPPS final rule

Making a checklist to prepare for the OPPS final rule

Editor’s note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.


The 2017 OPPS final rule will not be out for a couple of weeks, but that doesn’t mean providers can’t be thinking about what their action plan will be once the rule is released.

With only 60 days between the final rule’s release and the January 1 implementation date, providers will be ahead of the curve by spending time now and thinking about the processes they may need to review, change, or implement based on what CMS finalizes and the sort of financial impact the final rule is likely to have.

While I don’t know with 100% certainty what CMS will finalize, revise, delay, or back away from, I offer providers this list of what they should look at immediately upon the rule’s release.


Section 603

With Congress mandating payment changes for all non-grandfathered (those not billing under OPPS prior to November 2, 2015) off-campus, provider-based departments (PBD) starting January 2017, it was no surprise that CMS discussed this issue in the proposed rule. But it was a huge surprise to read CMS’ proposals, which, if finalized, would greatly impact otherwise protected grandfathered locations under Congress’ Section 603.

For example, CMS proposed that if an off-campus PBD moves, changes ownership, or expands its services beyond what it was providing as of November 2, 2015, as defined by APC-based clinical families, then its grandfathered status would be impacted. While this may sound relatively simple, the payment and operational impact would be a nightmare.

There is another aspect of Section 603 and CMS’ proposal to use the Medicare Physician Fee ­Schedule (MPFS) as the "applicable payment system" for ­Medicare Part B services provided at non-grandfathered locations or deemed "non-excepted." Specifically, there are many services for which the MPFS has no facility component for the facility costs associated with performing the procedure because they are only provided in hospital outpatient departments or ambulatory surgery centers. For these services, the industry has to wonder what CMS was thinking, as the agency cannot possibly expect to pay nothing for services that would continue to be rendered in off-campus PBDs.

CMS’ unexpected and hastily configured proposals create such large operational and financial problems that the industry is hoping the agency will simply retreat and delays the implementation of Section 603, or at a minimum revert to paying grandfathered facilities under the OPPS for all of their services, regardless of clinical service expansion, site relocation, or ownership changes. There is precedent for CMS to postpone implementation beyond statutory deadlines. If there were ever a situation where delay is advised, this is one.

Hopefully, providers sent in a surfeit of comments regarding these and other issues and outstanding questions related to the agency’s Section 603 implementation proposals. I hope CMS will acknowledge its proposals have administrative, operational, and financial gaps that are so large, it will be impossible to move forward by January. But even if CMS does choose to put off its proposals until proper payment mechanisms are developed, Congress was clear in its language requiring changes by January 1, 2017, so something is likely going to have to occur.

CMS’ proposals, if finalized, would have drastic long-term implications for all providers, including those who believe that their grandfathered status would protect them; the sad reality is that under CMS’ proposals, there will be massive operational and financial impact, so this is the first topic in the final rule that everyone should review.


Packaging proposals

Providers have gotten used to CMS expanding packaging in each OPPS rule, as the agency calls packaging an essential part of a prospective payment system. With CMS’ expansion of lab packaging from date of service to claim level this year, we should not be surprised if the agency finalizes its proposal of expanding the conditional packaging logic of CPT codes assigned to status indicators Q1 and Q2 to the claim level.

Claim-level packaging of these types of ancillary services will have a huge financial impact on providers submitting multiday claims, such as those for chemotherapy and radiation therapy services, despite the fact that multiday claims for these types of services are not required.

Currently, status indicators Q1 and Q2 are packaged into other OPPS services when provided on the same date of service, even when submitted on a claim that spans more than one day. If CMS finalizes its proposal, providers that continue submitting multiday claims when monthly or series claims are not required should not be surprised when they find themselves no longer receiving separate payment for many services.

This is the time for providers to assess whether they submit multiday claims for any services beyond the required repetitive services listed in the Medicare Claims Processing Manual, Chapter 1, section 50.2.2. While it is true the manual states that is is an option to bill nonrepetitive services on multiday claims, it did not have financial implications. At least, until this year, with the claim-based packaging of labs and proposal for claim-based packaging of Q1 and Q2 services. Providers should determine why they are billing multiday claims and what it would take to change their billing processes. If they elect not to move away from multiday claims, then assessing the financial impact that will occur is an important exercise to go through prior to January 1.

The other packaging proposal providers should look for in the final rule involves the use of modifier -L1 for reporting unrelated laboratory tests when they occur on a claim with other OPPS services. CMS proposes to delete the modifier for CY 2017 as it believes that the vast majority of labs should be packaged regardless of whether they are unrelated to other OPPS payable services.

This would have a big impact on providers who provide reference laboratory or nonpatient services, which the agency requires to be reported on the same claim as other OPPS services performed on the same date. Today, the use of the -L1 modifier allows providers to identify these services as separate and unrelated to the other OPPS services so that payment is received from the Clinical Laboratory Fee Schedule.

If CMS finalizes its proposal to eliminate modifier -L1, we can hope the agency will also update its instructions for reporting reference laboratory services so they can be separately paid even when provided on the same date of service or claim as other OPPS services. If CMS does not make a change, then providers can again expect to see a large financial impact. Both of these packaging proposals should be looked at immediately in the final rule.


Device-intensive procedures

The final set of proposals providers will want to review relates to the changes proposed for device-intensive procedures. This is a place where we hope to see CMS finalizing changes as proposed.

For example, CMS proposes to use the implantable device cost-to-charge ratio (CCR) to calculate pass-through device payments for hospitals that file cost reports designating that cost center, as this is a more accurate CCR for determining separate pass-through payment. Currently, only about two-thirds of hospitals use the implantable device CCR, which means the remaining one-third need to examine their cost reporting process.

Providers should determine whether they are in the group that reports the implantable cost center; if a provider is not reporting, it should find out why and begin making changes. This will have an impact on facilities’ ability to generate much better pass-through payment going forward, when applicable. It will also ensure future payment rates for device-intensive procedures reflect more accurate payment of the device.

Finally, it will be interesting to see whether CMS finalizes the addition of another 25 comprehensive APCs (C-APC) encompassing 1,844 additional status indicator T services; if it does, a financial impact analysis of these services will also be important, as this will be a large increase in C-APCs for a one-year span.

I plan to discuss these and other final rule changes in my next column, as well as in HCPro’s annual OPPS final rule webcast December 1 (see for details), but in the meantime I hope the above checklist will be useful to providers now and in the first weeks of the rule’s release. – Briefings on APCs

Has your CDI program shifted its focus for optimal PSI 15 performance?

Has your CDI program shifted its focus for optimal PSI 15 performance?

by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer

The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).

Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.

A fundamental understanding of patient safety indicator measures

Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:

  • The numerator: The numerator for PSI 15, also called the "outcome of interest," reports the actual number of cases which experienced the accidental puncture/laceration.
  • The denominator: The denominator for PSI 15, also called the "cohort," establishes the population which is screened to identify the outcome of interest.
  • Risk adjustment: Denominator comorbidities, which have a statistically demonstrated impact on the likelihood of a patient incurring the patient safety event. The risk adjustment methodology establishes the expected number of discharges with the outcomes of interest.


The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.

For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.


The new PSI 15?what counts?

The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).

The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.

From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.


PSI 15: Are you focused on risk adjustment?

Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.

The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.

The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.



Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.



Editor’s note:

Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or Opinions expressed are that of the author and do not represent HCPro or ACDIS. – Briefings on Coding Compliance Strategies