Recent News

FDG PET for Solid Tumors NCD Removes CED Requirement

The Centers for Medicare & Medicaid Services (CMS) has removed the coverage of evidence (CED) requirement in the national coverage determination (NCD) for fluorodeoxyglucose (FDG) positron emission tomography (PET) for solid tumors, effective June 11, 2013.

CMS will cover three FDG PET scans (without the CED requirement) when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same cancer diagnosis. Coverage beyond three scans for the same cancer diagnosis is up to the discretion of your local Medicare administrative contractor (MAC).

What this means for coders is that you no longer need to use modifiers Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study and Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study, along with condition code 30 Qualifying clinical trial or ICD-9-CM code V70.7 Examination of participant in clinical research on claims for these services.

Continue to report FDG PET or PET/computed tomography (CT) scans with CPT® codes 78608, 78811, 78812, 78813, 78814, 78815, 78816, with either modifier PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing for an initial scan or modifier PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy for subsequent scans.

Report also the associated supply with HCPCS Level II code A9552 Fluorodeoxyglucose f-10 FDG, diagnostic, per study dose, up to 45 millicuries and the same cancer diagnosis code.

Each different cancer diagnosis is also allowed an initial treatment strategy (modifier PI) scan and three subsequent treatment strategy scans (modifier PS).

For additional scans for the same cancer diagnosis, append modifier KX Requirements specified in the medical policy have been met.

Remember: To use modifier KX, additional documentation must be available to support the medical necessity of the service being performed in accordance with medical policy.

Source: MLN Matters® Number: MM8468

March 3rd, 2014

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ICD-10: Five Tips on How Your Bank Can Help

By Lisa M. Enright for AAPC

As healthcare providers across the nation prepare for the upcoming implementation of ICD-10,  planning should factor in the financial impact on your practice. As you prepare for the conversion, the magnitude of the changes on your employees, your patients and your bottom line should not be underestimated. There are practical expenses – as well as potentially hidden costs – you should be planning for today.

These five tips will help you identify items you need to consider and actions you need to take in anticipation of expanding capital and increased cash flow flexibility that will affect your practice both before and following the October conversion. Like many aspects surrounding the transition, to be fully prepared, it is prudent to address finances three to six months in advance of October.

  1. Understand Capital Needs –The complexity of the ICD-10 implementation will require software upgrades and extensive staff training in advance of the conversion. Your bank can construct term loans to address these capital expenditures.
  2. Arrange Working Capital Understand the average time it takes today to collect receivables, and expect the average time to lengthen significantly as practitioners learn the new codes. To backstop a longer receivables cycle, you should have access to three to six months of working capital reserves. Although you cannot control whether your payers will be ready and whether they are fluent in the new codes, an expansion of your working capital line of credit will help your practice manage available cash reserves through a period of delayed receivables. In advance of the conversion, talk to your banker about how to obtain or increase an existing line of credit.
  3. Before You Meet with Your Banker – Compiling essential documents before meeting with your bank will expedite the credit review and result in a fuller discussion of the practice’s financial needs. These documents should include tax returns for the prior three years for the practice and the principals, year-to-date interim financials, current Accounts Receivable Aging Report and an updated personal financial statement.
  4. Work with a Bank that Understands Your Needs – As the healthcare industry becomes more complex, it is important to work with a bank that understands the specialized financing requirements of healthcare practitioners. Some banks have specialized units dedicated to the healthcare professional. A knowledgeable banking partner who understands the full scope of your industry and operation – from posting and managing your receivables to establishing loans and lines of credit – can design financing plans that anticipate your short- and long-term needs.
  1. Widen Your Cash Flow Window – Rather than writing checks to pay for monthly operating expenses, use a business credit card to stretch out payments.  Some banks offer extended 50 day billing cycles which can provide additional cash flow flexibility. To avoid interest payments, pay your credit card bill in full each month.

About the Author

Lisa M. Enright is a Senior Vice President and Manager of the HealthCare Practice Banking Division for RBS Citizens Financial Banking. She can be reached at (860) 638-4471 or at


Find Important EHR Incentive Dates and Questions

CMS has posted important dates for Electronic Health Record (EHR) Incentive Program participants to mark on their calendars in 2014. And to provide further clarity for participants, it’s updated and includes new frequently asked questions (FAQs).
For EHR Incentive Program participants, here are important participation dates to remember:
  • March 31 (11:59 p.m. ET): It’s the 2013 attestation deadline for Medicare eligible professionals.
  • Sept. 30: It’s the end of 2014’s reporting period for eligible hospitals.
  • Nov. 30 (11:59 p.m. ET): It’s the 2014 attestation deadline for Medicare eligible hospitals.
  • Dec. 31: It’s the end of the 2014’s reporting period for eligible professionals.
The new and updated FAQs for the EHR Incentive Programs are broken into 10 subcategories on the CMS website to make it easy to find specific answers to your questions:
  • Certified EHR Technology
  • Eligible Hospitals
  • Eligible Professionals
  • Getting Started
  • Hospitals
  • Information for States
  • Meaningful Use & Clinical Quality
  • Medicaid Eligible Professionals
  • Medicare Eligible Professionals
  • Registration and Attestation
Go to the Source
To get a basic understanding of Medicare and Medicaid EHR Incentive Program, go to CMS’s “Medicare and Medicaid EHR Incentive Program Basics” webpage.
To answer your EHR Incentive Program questions, you can search by subtopics in the navigation bar on the left side of the “EHR Incentive Program FAQs“ webpage.

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Quality Data Posted on Physician Compare Website

Quality measures for 66 group practices and 141 Accountable Care Organizations (ACO) are now available to patients on the Centers for Medicare & Medicaid Services (CMS) Physician Compare website.

The quality measures posted include the following:

  • Controlling blood sugar levels in patients with diabetes
  • Controlling blood pressure in patients with diabetes
  • Prescribing aspirin to patients with diabetes and heart disease
  • Patients with diabetes who do not use tobacco
  • Prescribing medicine to improve the pumping action fo the heart in patients who have both heart disease and certain other conditions

The ratings displayed use stars to indicate measure performance and posts the actual percentage score.  Physician Compare already includes information about specialties offered by physicians and group practices, board certification, and affiliation with hospitals and other healthcare professionals. The Physician Compare site was created by the Affordable Care Act (Obamacare).

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Authenticate Services with Proper Physicians’ Signatures


Without a valid signature, you risk payer reimbursement.

By Susan Edwards, CPC, CEDC

The purpose of a physician’s signature in a medical record or operative report is to clearly identify who ordered and provided supplies or services for the patient. It also serves as a testament that the services he or she provided were accurately and fully documented, reviewed, and authenticated. Equally important: Payers deny claims unsubstantiated by the service provider’s signature. And not just any signature will do.

Acceptable Signatures

Each signature must be legible, and include the provider’s first and last name. The signature also should include the provider’s credentials (e.g., PA, MD, DO).

Medicare specifies acceptable methods of signing records/tests orders and findings, which include:

  • Handwritten signatures or initials
  • Electronic signatures usually contain date and timestamps and include printed statements, “electronically signed by” or “verified/reviewed by,” followed by the practitioner’s name and a professional designation.
  • Digital signatures are an electronic method of a written signature typically generated by encrypted software, allowing sole usage.

Note: Electronic and digital signatures are not the same as “auto-authentication” or “auto-signature” systems, some of which do not mandate or permit the provider to review an entry before signing. Documentation that has been “signed, but not read” is not acceptable as part of the medical record.

Acceptable signature examples:

  • Chart “accepted by” with provider’s name
  • “Electronically signed by” with provider’s name
  • “Verified by” with provider’s name
  • “Reviewed by” with provider’s name
  • “Released by” with provider’s name
  • “Signed by” with provider’s name
  • “Signed before import by” with provider’s name
  • “Signed: John Smith, MD” with provider’s name
  • Digitalized signature: handwritten and scanned into the computer
  • “This is an electronically verified report by John Smith, MD”
  • “Authenticated by John Smith, MD”
  • “Authorized by John Smith, MD”
  • “Digital signature: John Smith, MD”
  • “Confirmed by” with provider’s name
  • “Closed by” with provider’s name
  • “Finalized by” with provider’s name
  • “Electronically approved by” with provider’s name

Unacceptable Signatures

Reports or records dictated and/or transcribed that do not include valid signatures finalizing and approving the documents are unacceptable and will not serve to support claims for reimbursement. At one time, signature stamps were permitted, but they are no longer recognized as valid authentication for Medicare signature purposes.

Unique Signature Situations

Sometimes the lines of acceptability aren’t drawn quite as clearly.

Physician Left Practice

If a physician leaves a group practice before signing documentation for services he or she provided, another physician within the group may sign on his or her behalf; however, an explanation is required.

For example:

The submitting provider, John Smith, MD, is unable to sign this medical record because he expired on 10/08/13; or

John Smith, MD, relocated to Colorado on 10/08/13 and was unable to sign this medical record.


Incident-to a physician’s professional services means the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. Only the past, family, and social history and review of systems may be documented by ancillary personnel incident-to, and incorporated in to the evaluation and management (E/M) documentation, which must be reviewed and signed by the billing provider.

Electronic Health Records (EHRs)

EHR systems include a process that verifies that the individual signing his or her name has reviewed the contents of the entry, and has determined it contains the intended information.


Early laws required all physician assistant (PA)-written chart entries to be signed by physicians, but this is no longer the case. PAs may now sign under their own national provider identifier (NPI) for services they provide. Co-signatures may continue to be used, however, to ensure a physician oversees the practice of a PA.

The American Medical Association (AMA) states physicians are ultimately responsible for coordinating and managing patient care and, with appropriate input of PAs, ensuring the quality of healthcare provided to patients. Whereas The Joint Commission recommends each accredited organization determine the necessity for co-signatures.

Be sure to annually review physician/PA team policies for your practice and update them as needed to reflect changes in healthcare regulations.

Sloppy Signatures
Call for a Signature Log

Providers will sometimes include a signature log in the documentation that identifies his or her initials, or an illegible signature, as the author of the documentation. The signature log might be included on the same page where the initials or illegible signature appear, or it might be a separate document. Reviewers will consider all submitted signature logs regardless of creation date.

A signature log should include the physician’s printed name, full signature, and initials that appear on the document. The physicians can also list his or her credentials for further proof and validation.

Medicare transmittal 327 states that there are circumstances in which a provider does not need to sign an order for diagnostic testing. When the order is unsigned, the treating physician must include documentation, such as progress note indicating why he or she intended the diagnostic tests to be performed, and must authenticate this by a handwritten signature or e-signature.

Medicare does not require the ordering physician’s signature on laboratory service requisitions. Although the physician’s signature on a requisition is one way of documenting that he or she ordered the service, it’s not the only permissible way of documenting it. For example, the physician may document in the medical record that he or she ordered specific services.

Keep an Eye on the Time

Providers should not add signatures to the medical record beyond the short delay that occurs during the transcription process, which is generally 24-72 hours. Instead, providers may employ the signature authentication process. Per Medicare guidelines, Medicare Program Integrity Manual (Pub 100-08):

Late signatures may not be added to the record, beyond the short delay that occurs during the transcription process. Medicare does not accept retroactive orders. If the provider’s signature is missing from the medical record, submit an attestation statement from the author of the medical record. 

If the order is unsigned, you may submit progress notes showing intent to order the tests. The progress notes must specify what tests you ordered. A note stating “ordering lab” is not sufficient. If the orders and the progress notes are unsigned, your facility or practice will be assessed an error, which may involve recoupment of an overpayment. 

Signatures seem so insignificant in the grand scheme of things, but providers must be diligent and implement measures to ensure they are in compliance with signature guidelines. The consequences of non-compliance are grim.

Susan Edwards, CPC, CEDC, is lead outpatient coder at Copley Hospital Morrisville, Vt., and she teaches medical terminology at the local adult learning center. Edwards is a member of the AAPC National Advisory Board, northeast Region 1 representative, a past member of the AAPCCA board of directors (2010-2013), and is on the ethics committee for AAPC. She is a member of the Newport, Vt., local chapter.

March 1st, 2014

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