Results 1 to 8 of 8

CPMA - ABN question

  1. Default CPMA - ABN question
    Medical Coding Books
    In the Medical Record Auditor, Deborah Grider book - ch 1 pg 17, last paragraph, Proper Notice

    Can someone please help me understand this paragraph

    "If the determination is not favorable, the beneficiary has no appeal rights but may receive the service and have a claim submitted to the contractor. If the claim is denied, the beneficiary can pursue an appeal through the regular appeals process. A beneficiary who decides against the prior determination process but chooses to receive the service and seek coverage retains appeal rights."

    I understand if services are not covered by Medicare the patient can still chose to have the service and then can submit a claim, then if the claim is rejected via medicare payment, can pursue payment through regular appeals process. Question: are they /can they only pursue through regular appeals process with other insurance (not Medicare)

    Secondly, I'm not sure of the last sentence, does this mean if beneficiary still chooses to have the services, they can look for coverage other than Medicare and this allows them to have appeal rights? I know I'm missing something here

    Thank you.

  2. #2
    Default
    Quote Originally Posted by arizona1 View Post
    In the Medical Record Auditor, Deborah Grider book - ch 1 pg 17, last paragraph, Proper Notice

    Can someone please help me understand this paragraph

    "If the determination is not favorable, the beneficiary has no appeal rights but may receive the service and have a claim submitted to the contractor. If the claim is denied, the beneficiary can pursue an appeal through the regular appeals process. A beneficiary who decides against the prior determination process but chooses to receive the service and seek coverage retains appeal rights."

    I understand if services are not covered by Medicare the patient can still chose to have the service and then can submit a claim, then if the claim is rejected via medicare payment, can pursue payment through regular appeals process. Question: are they /can they only pursue through regular appeals process with other insurance (not Medicare)

    Secondly, I'm not sure of the last sentence, does this mean if beneficiary still chooses to have the services, they can look for coverage other than Medicare and this allows them to have appeal rights? I know I'm missing something here

    Thank you.
    "If the determination is not favorable, the beneficiary has no appeal rights but may receive the service and have a claim submitted to the contractor. If the claim is denied, the beneficiary can pursue an appeal through the regular appeals process. A beneficiary who decides against the prior determination process but chooses to receive the service and seek coverage retains appeal rights." I don't think "appeal rights" and the ability to "pursue an appeal through the regular appeal process" are quite the same thing, but I could be wrong. I think that once they learn that a procedure may not be covered, they can opt to have a pre-determination to see before getting the service. I believe that once they've been told that it won't be covered, they can't appeal the pre-determination. They can still appeal the claim denial on their own - it's their time to waste.

    Here's what you need to know about ABN's for the test:
    What ABN stands for.
    ABN's only apply to Medicare. Period.
    ABN's can't be all-encompassing. You can't make patients sign a blanket ABN. They also can't be attached to anything else, like a notice of privacy practices.
    Know the modifiers GX, GY, and GZ, and when to use them.
    Know when you'd need to have one, and what happens if you can't/don't get one.
    Read this: http://www.mayoclinic.org/becomingpa...-abn-faqs.html
    I don't remember a whole lot of questions about ABN's, but I'm sure there were a few. They probably didn't make much of an impression on me because the questions weren't as hard as other areas of the test - I either knew the answer, or could figure it out through the process of elimination.

    I strongly suggest shift your worry/focus to RAC audits, RAT-STATS, Corporate Integrity Agreements, Business Associates, and anything with "OIG" on the page. Those topics DID make an impression on me.

    If you come across a lot of confusing things in the book, know that it's not just you...I found all kinds of problems with the book that were extremely confusing - typos, contradictory statements, etc. - Just a complete lack of proofreading. I have a funny story about how I handled it, but that's best left for another day!

    Good luck!
    Last edited by btadlock1; 04-04-2011 at 10:58 PM.

  3. Default
    Thank you so much! Yes, it is very frustrating trying to study from a book of double talk and errors. Not to mention I found differences between the NAMAS and the Deborah Grider books.

    Thanks again for your help!

  4. #4
    Location
    Sarasota FL
    Posts
    923
    Angry CPMA test
    I too find 'Medical Record Auditor' ambiguous, inaccurate in places, and full of typos. I then bought the NAMAS guide following recommendation from a CPMA (which is not on the AAPC recommended study list for the test, but which is an AAPC book)..... all rather confusing. The NAMAS guide is better I think but is ridiculously expensive and still has plenty of typos (and some errors) to negotiate.
    Brandi, I'd love to learn how you handled the contradictions and proof-reading errors; they irritate me to the point of distraction.

  5. #5
    Post It's a bit of a long story...
    Quote Originally Posted by wassock View Post
    I too find 'Medical Record Auditor' ambiguous, inaccurate in places, and full of typos. I then bought the NAMAS guide following recommendation from a CPMA (which is not on the AAPC recommended study list for the test, but which is an AAPC book)..... all rather confusing. The NAMAS guide is better I think but is ridiculously expensive and still has plenty of typos (and some errors) to negotiate.
    Brandi, I'd love to learn how you handled the contradictions and proof-reading errors; they irritate me to the point of distraction.
    A little bit of background: I had virtually no auditing experience (or even coding, really - I just did claims follow-up for 3 years); I couldn't afford the conference, and I'm one of the only people in my area with a CPMA certification - even now (and I got mine in October), I didn't really use the forums then, either, so I couldn't get anyone to help me figure out why I was getting the wrong answers on my E/M audits. (I was getting hung up on the exam, as usual, and I wasn't very good at the History yet, either. Oddly enough, I got the MDM right every time. I couldn't figure out where my mistakes were, because there was no rationale for the answers in the book. They just were what they were, and most of the time, I was off by one level.

    I got all the way to the end of the E/M, and was working on the practice audit cases, and was getting really frustrated, because I couldn't tell if I was really just not understanding the material correctly, or if there were errors in the answer key. I decided I'd had enough, when I got to one E/M that I came up with 99205, and the answer key said 99202. After getting some practice and feedback from others, I understand it now, but at the time, I just did not get what I was doing wrong.

    In October, I only had a CPC-A, because my boss hadn't given me a letter on company letterhead, saying I'd been working there for 3 years, so I could get the "A" off of my CPC. I think that it had a major affect on the way I was treated...I emailed the AAPC, at my wit's end, desperately asking for someone to look into the errors in the book, and explain to me how they came up with the answer to that audit case. I figured I'd given too much credit in the History or Exam somewhere, but couldn't figure out where. I gave examples with specific page #'s, of major errors - I wasn't trying to be tacky - I just wanted it to be easy for whoever read the email to know what I was talking about. I made my desperate plea for help, and didn't expect to get a response - I had the 2nd Edition of the book, and they'd just released the 3rd one, so I figured I'd be blown off. I've actually still got the emails, so I'll just paste them into here so you can see what happened, and judge for yourself. When I sent the first email, I was frustrated. When I sent the reply, I was mad. I attached copies of the pages I had found errors on, and circled the errors, along with anything else I referenced.

    To Whom It May Concern:

    I'm not sure who I should really be contacting about this, but I have a few questions regarding the CPMA Exam, and over the information in the textbook, Medical Record Auditor, 2nd Edition. I apologize if this note seems more like a complaint than an inquiry; I've reached the point that I'm frustrated and anxious about whether I'll be prepared to pass my exam in 2 weeks.
    I've been studying to take the CPMA exam on my own, since I can't locate anyone offering a preparation course, except for the AAPC's 2-day, $700 seminar in Dallas, which I can't even afford to travel to, much less, attend. I've worked as a commercial insurance specialist for a physician practice management group, following up on outstanding and denied claims for over 150 providers of various specialties, for nearly 3 years. I've appealed countless denials successfully, based on coding guidelines, payer policies, and HIPAA regulations, and have gained a wealth of knowledge on those subjects. I review medical records on a daily basis to determine whether or not claims were coded correctly, whether or not medical necessity has been established for many procedures, and to verify that our claims are consistent with the documentation. When I read about being a medical record auditor, it seemed like something that I would enjoy doing, so I decided to become certified so that I could someday steer my career in that direction. I've followed the suggestions on the AAPC's website to prepare on my own, to the letter. That included purchasing the Medical Record Auditor, 2nd Edition, as a tutorial guide. At the time that I bought the book, about 3 months ago, there was no mention of a 3rd edition's impending release, otherwise I would have waited to get more updated material.
    I've gone over all of the material in chapter 6 regarding physician consultation codes, and Medicare's payment policies on them, but since Medicare changed its policy this year to virtually abolish payment for consult codes, I wanted to find out which policy year, if any, will be covered on the CPMA exam, so that I may prepare accordingly.
    I've discovered several errors in the textbook that are annoying, and occasionally confusing. For example, Table 3-8 on page 95 has all of the information on the second line shifted one position to the left, so it looks like the required elements for a comprehensive exam are "1997 Single Organ System Exam", and all of the other levels show requirements for the next level up. Also, there are several refences throughout the book, and particularly in chapter 7, to an audit tool and blank charge ticket in Appendix B; neither of which are in my book. My Appendix B is the CMS Documentation Guidelines for 1995 and 1997. I did find 3 audit tools in Appendix C for E/M coding (still no superbill, though), but I wasn't sure which I'm supposed to use for the practice tests. Those kinds of errors made it apparent that little or no proofreading had taken place before this edition was published, aside for spell checking. So when I've missed questions in the "Test Your Knowledge" sections, I can't always be sure if I really didn't answer the question correctly, or if it was another careless mistake. The answers on the CD-ROM rarely offer any rationale, which is important in understanding why I got an answer wrong, and ultimately, what areas I need to focus on improving.
    For example, I missed several aspects on one of the audit exercises in Chapter 7 (Case #3), according to my curriculum. I had coded the encounter as 99205, because I interpreted the history and exam to be comprehensive, and the medical decision making as high. I struggled with the MDM, because according the the points system, I thought that the number of diagnosis options and amount/complexity of data were extensive, but that the risk was only moderate, so I was on the fence about whether the overall MDM should be considered moderate or high. I eventually settled on 99205, because the CPT definition says that the presenting problems are usually moderate to high severity, and I could believe that the encounter might have taken around 60 minutes in face-to-face time. I was expecting to see that the correct answer was 99204, if I had missed it - I'm usually only one level off, and I can see where I went wrong, most of the time. I was thoroughly confused when I saw that it should have been 99202, and have a few questions.
    Starting with the exam: Why was no credit given to skin or psychiactric? I might be misinterpreting the bullets, but I would have given credit to skin for the notation "no erythema or ecchymoses", under the bullet for "inspection of skin and subcutaneous structures", and the mention of the patient appearing anxious seemed to fit under the patient's state of mind, rather than a constitutional observation. As a follow-up question, what kind of documentation would be a correct example of anxiety documented as psychiactric?
    My biggest area of confusion is that the answer key says that 13 bullets were documented, but somehow that only added up to an expanded PF exam. That completely contradicts the tutorials and CMS guidelines, which all indicate that 13 bullets = detailed exam. Where did that answer come from?
    Also, I noted that 36415 was not documented, because I didn't find any mention of a venipuncture in the record. It did say that the patient was going to be scheduled for "laboratory studies", but didn't indicate that any blood was drawn during the visit, or that any of the labs would even involve blood at all. I could have seen the link if the notes had said something more specific, like "ordered CBC", or something along those lines, but without even mentioning a lab that was blood-specific, I couldn't see any justification in coding a blood draw that wasn't mentioned in the notes. Also, I wasn't sure if it mattered, but I had the primary diagnosis as 414.00, because there's a note in my ICD-9-CM under 413.9 that states: "Tip: For patients with both angina and coronary artery disease, sequence the CAD [subcategory 414.0] code first."
    I'm sorry to present you with so many concerns at once, but I just want to be sure that I understand why I'm not getting the right answers, and I don't have the benefit of having an instructor available to help me see what I'm doing wrong. The answer key for the second edition is not adequate for helping me learn from my mistakes; if I don't know why your answer is right, I can't possibly figure out why my answer is wrong, particularly when dealing with something as complex as E/M coding, where there are numerous opportunities to make a mistake that effects the overall code selection. Additionally, the fact that there are a lot of obvious errors in the book makes me second guess all of the answers, and leaves me doubting that I'm learning everything correctly, even when I do come up with the correct answer. Please explain the rationale regarding the questions I've asked, so that I can correct my course before the test. Thank you.


    Have a Great Day!
    Brandi Tadlock, CPC-A
    Brandi:

    First of all there is a 3rd edition that has been updated for Medical Record Auditor. I suggest that you purchase that edition which will have all updated information. I believe you are confused and I do recommend you take a course. You are a CPC-A and that tells me you do not have the industry experience necessary to successfully pass the CPMA examination without an instructor to explain auditing to you which is different than coding. I am not finding the errors you are finding. If you are having trouble selecting your levels for E/M it is most likely the MDM. Determining the overall level is more than identifying key components, it should also include medical necessity. If the provider has a 99205 documented with the key components, it doesn’t necessarily make it a level 5 visit if medical necessity does not support it.


    Deborah Grider
    AMA Author
    Deborah,

    I appreciate you taking the time to respond to me; however I find the condescending and dismissive nature of your reply insulting, and unhelpful. As I mentioned before, I would have happily purchased the 3rd edition of your book, had I been aware that it was due to be released soon after I bought the 2nd edition, but there was no mention of it on the AAPC's website anywhere.

    Secondly, I mentioned the work experience I have in anticipation of you telling me that I'm not ready to take your exam, due to the apprentice status on my credentials. The fact that I still have the "A" is not a reflection of my lack of experience, it's a technicality resulting from my supervisor's delay in providing the letter of recommendation that I need to have it removed. He actually took care of it today, so it should be removed soon. (I've attached a copy of it.) In reality, I should have been considered a "CPC" and not "CPC-A" from the moment I passed the exam with a 90 last year. I am not employed as a coder. I analyze denied claims to find errors, both on our providers' part and on the insurer's part, in order to either locate areas that need correcting, or appeal claims that have denied without merit. That goes far beyond just coding; making assessments of medical necessity and the accuracy of provider documentation, are routine aspects of my job. I realize that I don't have the auditing experience recommended to pass the CPMA, but I'm going to take the test in spite of that, just to see what I'm capable of achieving.

    None of that changes the fact that there ARE errors in your book and answer key that are hindering my ability to assess my skills and find where I need improvement.

    Since you're having trouble locating them, I've attached copies of the pages I was referencing, as well. Maybe I just got a bad copy of the book; in any case, you haven't addressed all of my questions, and I believe that I do have some valid concerns. So, if you have a minute, I'll ask again.

    1. The answer key indicates that for Case 3 in Chapter's 7's practice audits, the overall code selected was 99202. The component that had the greatest impact on the code selection was the Exam, since all 3 components must be equal for a visit to qualify for a given level of service for a new patient, and the Exam was assigned the lowest level. The answer key states: "13 bullets documented", and that somehow, the level of the Exam was Expanded Problem Focused, 99202. Please explain to me how 13 bullets, from a variety of organ systems, only qualifies as an EPF exam.
    - If you look at the first page I've attached from the book, you'll see the chart showing the 1997 CMS exam documentation guidelines. The top portion (the one without any typographical errors), says that for a multisystem exam to be defined as Detailed, "2 elements defined by a bullet from 6 body areas/organ systems OR 12 elements from at least 2 body areas or organ systems". That information is repeated in the text below, in case the chart isn't clear enough. Even without years of auditing experience, I feel pretty confident that 13 is greater than 12. I do not understand how you determined that the level of the Exam component was only Expanded Problem Focused.

    2. In reference to that same case, I do not see ANY documentation that supports billing 36415. Perhaps my example chart note was worded differently from yours. Please see the copy that I've attached (pages 6 & 7). What phrase in that note supports billing for the performance of 36415?

    3. The note says that the patient appeared "mildly anxious", and your answer key gives credit to the Constitutional area of the exam for that statement, as an assessment of the patient's overall personal appearance. It's probably a misinterpretation on my part, but I thought that the "patient appearing mildly anxious" would be better described as "Brief assessment of mental status including: mood and affect (eg, depression, anxiety, agitation)", under Psychiatric in the 1997 exam guidelines (attached, page 8), than the overall appearance of the patient in Constitutional. What is an example of a phrase that would be documented, that would correctly indicate that the provider was noting anxiety as a mental assessment, and not as a constitutional one?

    4. Where are the "audit tool" and "charge ticket" located that you are referring to in Chapter 7, that are supposed to accompany the exercises? (see attached, pages 2 - 5)

    I agree that having the benefit of an having an instructor to ask these questions to would be a tremendous help. But once again, as I mentioned in my previous email, there are none within a minimum of 500 miles from here. I haven't even been successful in finding one person who has actually taken the CPMA exam locally to ask questions to. I am taking the exam on October 23rd, and will make my best attempt to pass it, with only the experience I have now, and the things that I have learned from your book. If I fail, then I fail. It shouldn't be of any consequence to you or anyone else, if it turns out that I wasted $300 and 5 1/2 hours of my time, so I would sincerely appreciate it if you would take me seriously on the questions that I'm asking you, even if you don't agree with me asking them, with my meager 3 years of industry experience. Surely someone with your expertise is capable of explaining something as simple as how you got the answer to a question that you made up. If not, then thanks for your time, anyways.

    Have a Great Day!
    Brandi Tadlock, CPC-A
    I never got a reply. This all went down on October 11th; I was so furious, that I studied 10 times harder, just to prove her wrong. I honestly don't think she even read my first email; her reply certainly didn't show it, if she did. It seemed like she saw the CPC-A, and then skimmed the message, picked out a few key words, and spit out a reply as quickly as possible (perhaps she thought I was wasting her time with elementary questions...who knows.) Anyways, in the end, I passed the test the first time, and found out on October 29th - it was awesome, but even more so, because I knew that at least one person was counting on me to fail. I had to send her one more message:

    I just thought you might be interested to know that I did pass the exam on my first attempt. Thanks!

    Brandi Tadlock, CPC, CPMA
    Keep on truckin', ladies! If you're here asking questions, you're already a step ahead of where I was!
    Last edited by btadlock1; 04-04-2011 at 07:37 PM. Reason: found my original email

  6. #6
    Location
    Sarasota FL
    Posts
    923
    Default Long story...
    Brandi. What a great story and more power to you for following your instincts and standing up for what you thought was right. How can recommended study material be so wrong? I'd love to be a proof reader for any kind of medical book/journal or whatever because I know I can do a far better job than most of these people. It's a shame your query was treated in such a dismissive way but there was only one winner.
    Anyway, power to you ladies ( I'm a guy but I back you all the way... why wouldn't I, you were right?)

  7. #7
    Default
    Quote Originally Posted by wassock View Post
    Brandi. What a great story and more power to you for following your instincts and standing up for what you thought was right. How can recommended study material be so wrong? I'd love to be a proof reader for any kind of medical book/journal or whatever because I know I can do a far better job than most of these people. It's a shame your query was treated in such a dismissive way but there was only one winner.
    Anyway, power to you ladies ( I'm a guy but I back you all the way... why wouldn't I, you were right?)
    Sorry! I wasn't trying to emasculate you, there! I don't know if the AAPC has someone who proofreads those before publication, but they should really get someone if they don't. It's a widespread problem (I also saw it with the CPC curriculum, which is a big part of the reason I didn't spend the money for the CPC-P guide.) Personally, I would have taken offense to the fact that there were errors in a book that had my name on it, and I probably wouldn't have been defensive with someone for bringing it to my attention. I think I'd be upset that I put a lot of time and effort into creating something that ended up looking sloppy and carelessly thrown together, because nobody bothered to read it before printing and selling it. (Or because no one thought I was capable of making a mistake; therefore no one checked my work.) But, then again, I take a lot of pride in my work and it is a big deal to me if my name is associated with a crappy job.

    I'd gotten over my anger with the situation long ago, but I kept the emails because even though it was 'negative', that experience was the biggest motivator I've had in a long time, and it reminds me that other people don't know my potential, so if I listen to others instead of trusting my abilities, I might never reach the level of success that I'm capable of reaching. (as corny and cliche as it is, it's just a reminder of how things work out when you "believe in yourself".) And really, that's my whole point in posting it on here, too. That, and I think it's kind of funny.

    I'm with you, though - if they ever do get on the ball and hire some real editors, I'll gladly offer up my critiquing-services!

  8. #8
    Location
    White Plains, NY
    Posts
    123
    Cool
    I just came upon this story - you are absolutely right! The book is FULL of errors that made it all the more confusing to study! And I had the same problem that AAPC never mentioned the new one was coming out; I felt ripped off. It also makes me wonder if anyone has purchased the 3rd edition and if there are substantial correction/changes in it.

    AAPC has ventured into the Auditing field, and now I see they are also offering a compliance certificate. I was lucky that where I live a CPC still carried some weight. Collegues in other parts of the country need to have a CSS, which is more and more in demand here as well. I think AAPC should concentrate on its core membership needs, rather than branching out again. It makes me think they are actually diluting their influence by spreading too thin.

    Anyway - my two cents!

    Lin
    CPC, CEMC, CPMA

Similar Threads

  1. ABN question
    By vpat28 in forum Ophthalmology/Optometry
    Replies: 1
    Last Post: 04-04-2013, 03:48 AM
  2. ABN's question
    By Justarose in forum Hematology/Oncology
    Replies: 1
    Last Post: 12-23-2009, 11:49 AM
  3. ABN Question
    By yvette31 in forum Cardiology
    Replies: 2
    Last Post: 04-04-2008, 09:29 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.