Reinhard Wolfgang Beel, C.E.C, C.D.T.

1. Reinhard Wolfgang Beel, C.E.C, C.D.T. Administrative Consultant for Endocrine Offices 49 Brookwood Avenue Carlisle, PA 17015 Tel: 717-798-4820 (Cell) Tel: 717-258-6002 (Business) Fax: 717-258-8164 -Good Evening Ladies and Gentleman, -I am the business manager for Cumberland Valley Endocrinology Center in Carlisle Pennsylvania which is owned by Doctor Andrew J. Behnke. -Dr. Behnke opened this practice in August of 2002 and wanted to be on the cutting edge of technology giving our patients , the highest quality of health care and doing this in a profitable way. -three years ago � 1 provider and two employees -purchased ultrasound machine -lab -Started with a zero patient base -Electronic medical records 3 years later -3 Providers----1 Registered Diatitien----2 Nurse Educators----1 Lab Technician (10.000 Lab Assays)----8 Support Staff---2 fulltime Research Coordinators We perform Ultra sounds----FNA----I 131 Treatments----ADA Certified Diabetes Education Center ( bill Medicare and third party payors for education)-----Research Why do I tell This was only possible thru correct coding and billing - I can tell you that endocrine coding is not as complicated as you might think. -Of course there are rules to follow, but they can be put into simple terms and easily understood. -Having said that, lets see what we have in our program tonight.-Good Evening Ladies and Gentleman, -I am the business manager for Cumberland Valley Endocrinology Center in Carlisle Pennsylvania which is owned by Doctor Andrew J. Behnke. -Dr. Behnke opened this practice in August of 2002 and wanted to be on the cutting edge of technology giving our patients , the highest quality of health care and doing this in a profitable way. -three years ago � 1 provider and two employees -purchased ultrasound machine -lab -Started with a zero patient base -Electronic medical records 3 years later -3 Providers----1 Registered Diatitien----2 Nurse Educators----1 Lab Technician (10.000 Lab Assays)----8 Support Staff---2 fulltime Research Coordinators We perform Ultra sounds----FNA----I 131 Treatments----ADA Certified Diabetes Education Center ( bill Medicare and third party payors for education)-----Research Why do I tell This was only possible thru correct coding and billing - I can tell you that endocrine coding is not as complicated as you might think. -Of course there are rules to follow, but they can be put into simple terms and easily understood. -Having said that, lets see what we have in our program tonight.

2. CODING FOR MAXIMUM REIMBURSEMENT U/S (Ultrasound) FNA (fine needle aspiration) DEXA (dual energy x-ray absorptiometry) Nerve Conduction Study ABI (ankle brachial index) Fundus Photography Counseling POC (point of care) Testing Insulin Pumps and CGM (continuous glucose montoring) Shared Medical Appointments

3. ULTRASOUND EQUIPMENT Costs between $15.000 - $60.000 Reimbursement approx.: $ 103.50 MC 2009 fee-schedule for U/S. Reimbursement approx.: $ 134.55 MC 2009 fee-schedule for U/S guidance for FNA

4. Average reimbursement for U/S or U/S- Guidance approx. $115.- U/S Equipment cost approx. $60.000/$115 = 522 Studies 522/24Month=22 U/S per month 22/20 work days = 1 U/S per day ROI with 1 U/S per day = 2 years Last 12 Month� 784 U/S and 182 FNA U/S EQUIPMENT

5. Are post-menopausal? Have a history of fractures? Have long term steroid use? Are over 50 years old?

6. Reimbursement was reduced this year at request and after a study performed by CMS (with only radiologists), resulting in a reduction in RVU values by more than 50%. A study performed by multi-specialties revealed that the RVU�s where at the correct value in past years. Is there a hidden agenda by radiologists to reduce DEXA performance by other specialties?

7. In most states, nerve conduction studies can be performed by a trained medical assistant (MA) while the patient is in the office Excellent reimbursement (from $100-$350) Code according to what nerves are stimulated (ex. 95903 and/or 95904 in multiples) Make sure the company you deal with is reputable Be certified in reading and interpreting results Document correctly Excellent patient care procedure

8. ADA suggests checking anyone at risk for PAD (over 50, diabetic, hypertension, dyslipidemia or with other indications of PAD) Insurance companies request ABI done on patients at risk for PAD (send letters) Doppler can be purchased for less than $1000 Reimbursement = approx. $120 Return on investment with the first 8 patients Do not use DM (250.xx) code alone ABI code 93922 Can be done by MA

9. FUNDUS PHOTOGRAPHY Possibly lease camera MA is trained to capture photo (no interpretation involved by MA) Have interpreted by local Ophthalmologist (create more work not take it away) Use non-dilated photo (less liability) Reimbursement PA Medicare $70.70 Code 92250

10. COUNSELING Remember counseling can be billed by time (if more than 50% of the time was spend counseling) Time determents the level of visit 99215 is the correct level if 21 minutes out of 40 was spent counseling. 99406: 3-10 minutes and 99407: >10 minutes should be used for smoking cessation

11. POINT OF CARE TESTING BNP (TZD-CHF), GLU, HbA1c, Lipid Panel, Microalbumin, Urinalyses CLIA waived tests Machine and reagents must be bought to bill for the test Results with in 5 � 10 minutes Payment between $5 and $50 depending on test performed Some equipment is free with reagent rental

12. Insulin Pumps Have a Certified Pump Trainer on staff Contract with the pump companies for reimbursement of pump training. Utilize DSMT and MNT to get the patient ready for the pump (carb counting) Management and follow-up visits are E/M visits

13. CURRENT CGM BILLING 99212-99215 (E&M): Patient Evaluation Session Comprehensive medical hx Review of past glucose monitoring Evaluation of A1c and glucose control Review medication regimen etc. 95250: Patient CGM Initiation session Pt wears CGM device for minimum of 72 hours: includes training, hookup, calibration, removal, and download 95251: Physician Interpretation and Report Physician reviews and interprets CGM data and generates report

14. FAQs REGARDING 95250 / 95251 Can an RN or CDE bill 95250? An RN or CDE can provide the services of 95250 under proper physician supervision, and the physician can bill for those services. What documentation is needed to bill 95251? Provider should contact their payers for specific coverage criteria. It is our understanding that physicians should document analysis and interpretation. CGM reports should be printed and included in patient�s medical record. Can a CDE or RN bill 95251? No. 95251 is a professional code only billable by an MD, NP, CNS, or PA (as appropriate).

15. NEGOTIATING FOR PAYMENT Determine the payer(s) based on the number of beneficiaries you see

16. SHARED MEDICAL APPOINTMENT (SMA) In the past, access was ensured by adding space and new providers Declining reimbursement for services demands greater productivity Shortages in key specialties Even higher levels of demand for the �best� providers

17. This slide shows a typical office set-up for a Shared Medical AppointmentThis slide shows a typical office set-up for a Shared Medical Appointment

18. SHARED MEDICAL APPOINTMENT OVERVIEW Bill as individual appointments (E/M Visit codes) Code according to level of care delivered and documented Do not bill for counseling time (time on the clock can only be used once for counseling) Prior to visit, all patients and support personnel sign a patient privacy release (HIPAA compliance)

19. Random Glucose (82947) every visit HbA1c (83036 or 83037) up to 4 per year ABI Fundus Photography (92250) 1 per year Lipid Panel (80061) 1 per year Set up DMST group visit with SMA (bill on separate claim if ADA recognized DSMT Education Center)

21. IT ALL ADDS UP! Let�s put it all together. A PATIENT CASE YOU ALL CAN RELATE TO:

22. 51-year-old male referred to your office by PCP for suspected thyroid nodule and DM. He has a documented history of HTN and dyslipidemia. The patient had noticed his shirt collars are becoming tight. Glucose, HbA1c, and lipid panel by finger stick, with POC Devices performed. Records are reviewed and physical exam reveals a palpable left thyroid nodule as well as retinopathy, HbA1c 8%, GLU 210, BP-150/90, LDL 150. An U/S is performed and confirms the nodule. You perform a FNA under U/S guidance. The slides are evaluated under microscope for adequacy of samples, packed up, and sent to the pathology lab for evaluation. DM, BP, lipids are addressed appropriately. A Fundus Photo is done to evaluate retinopathy, an ABI is performed to evaluate PAD. TSH and FT4 are ordered, drawn, and analyzed in your office lab. I wanted to share at least 1 example with you, so you can see how important correct coding is I have to tell you that this is the most exciting part of coding It is sometimes challenging to find all the necessary codes that are involved in one office visit. This could be a typical office visit: --A 51-year-old male is referred to your office by his PCP for a suspected thyroid nodule with a documented history of hypertension and diabetes. The patient had noticed that his shirt collars are becoming too tight. --A glucose by finger stick is performed and shows 146 Glucose. -- Records are reviewed and a physical exam reveals a palpable left thyroid nodule. --An ultrasound is performed in the office and confirms the nodule. --You decides to perform a fine needle aspiration under ultra-sound guidance. --The slides are evaluated under a microscope for adequacy of samples, packed up and send to the pathology lab for evaluation. --A TSH and FT4 are ordered, drawn and analyzed in the office lab. I wanted to share at least 1 example with you, so you can see how important correct coding is I have to tell you that this is the most exciting part of coding It is sometimes challenging to find all the necessary codes that are involved in one office visit. This could be a typical office visit: --A 51-year-old male is referred to your office by his PCP for a suspected thyroid nodule with a documented history of hypertension and diabetes. The patient had noticed that his shirt collars are becoming too tight. --A glucose by finger stick is performed and shows 146 Glucose. -- Records are reviewed and a physical exam reveals a palpable left thyroid nodule. --An ultrasound is performed in the office and confirms the nodule. --You decides to perform a fine needle aspiration under ultra-sound guidance. --The slides are evaluated under a microscope for adequacy of samples, packed up and send to the pathology lab for evaluation. --A TSH and FT4 are ordered, drawn and analyzed in the office lab.

23. The following is coded as diagnosis: Thyroid Nodule � 241.0 Diabetes Type 2, with Retinopathy, uncontrolled � 250.52 Benign Essential Hypertension � 401.9 Dyslipidemia � 272.4 The following is coded and documented as Diagnosis: Thyroid Nodule � 241.0 Diabetes type 2 no complications � 250.00 Benign Essential Hypertension 401.1 The following is coded and documented as Diagnosis: Thyroid Nodule � 241.0 Diabetes type 2 no complications � 250.00 Benign Essential Hypertension 401.1

24. THE FOLLOWING PROCEDURES ARE CODED: PA MEDICARE 99244 -25 Separately identifiable E/M visit $ 179.55 36415 Blood collection $ 3.00 82947 Glucose Assay (Lab level Analyzer) $ 5.48 80061 Lipid Panel $ 18.72 83036 HbA1c $ 13.56 93922 -59 Extremity Study (ABI) $ 112.95 92250 -59 Eye Exam w/Photo, Fundus Photography $ 70.70 76536 -59 Separately identifiable Procedure $ 103.50 10022 Fine needle Aspiration under U/S $ 124.32 guidance 76942 Ultrasound guidance for Fine Needle $ 172.69 Aspiration 88172 Immediate cytohistologic study to determine $ 49.89 adequacy of specimen 84443 TSH $ 23.47 84439 FT4 $ 12.60 TOTAL: $ 890.43 The following Procedures are coded: PA Medicare 99245 -25 Separately identifiable E/M visit $ 214.83 36415 Blood collection $ 3.00 82947 Glucose Assay (Lab level Analyzer) $ 5.48 76536 -59 Separately identifiable Procedure $ 88.08 Fine needle Aspiration under Ultra-sound $ 138.75 Guidance 76942 Ultrasound guidance for Fine Needle $ 134.55 Aspiration 88172 immediate cytohistologic study to determine $ 49.30 adequacy of specimen 84443 TSH $ 23.47 84439 FT4 $ 12.60 Total: $ 670.06 The following Procedures are coded: PA Medicare 99245 -25 Separately identifiable E/M visit $ 214.83 36415 Blood collection $ 3.00 82947 Glucose Assay (Lab level Analyzer) $ 5.48 76536 -59 Separately identifiable Procedure $ 88.08 Fine needle Aspiration under Ultra-sound $ 138.75 Guidance 76942 Ultrasound guidance for Fine Needle $ 134.55 Aspiration 88172 immediate cytohistologic study to determine $ 49.30 adequacy of specimen 84443 TSH $ 23.47 84439 FT4 $ 12.60 Total: $ 670.06

25. Must have 2 or more DX codes to use Mod. 25 Several nodules can be billed separately Use Mod �LT�, �RT� And �51 Multiple Procedures� Some procedures will be paid at 50% 2 and more U/S can get paid with Mod �59 Separately Identified Procedure�

26. The most important ways to maximize reimbursement: Code and document correctly Code all services done and documented Add additional services according to standard of care (ABI, POC Lab Tests, NCS, Eye Exam, DEXA)

27. RE-WORK REJECTIONS & RE-SUBMIT CORRECTED CLEAN CLAIMS UNTIL THEY ARE PAID