Please note these are dated articles. Up-to-date policies AND CODES should be referenced in conjunction with this information.
Permission is granted to print and share, provided author is credited
inter 2016 Communique
2016 Coding Updates for Anesthesia
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/component/content/article/89-communique/current-issue/winter2016/861-2016-coding-updates-for-anesthesia
2016 Coding Updates for Anesthesia
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/component/content/article/89-communique/current-issue/winter2016/861-2016-coding-updates-for-anesthesia
Winter 2014 Communique
Reporting Postoperative Pain Management in 2014
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/index.php/publications/communique?id=679
Reporting Postoperative Pain Management in 2014
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/index.php/publications/communique?id=679
AAPC Articles may require membership to access
March, 2017, Healthcare Business Monthly, Quality Reporting for Anesthesia Services: Then and Now
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
www.aapc.com/blog/37862-quality-reporting-for-anesthesia-services-then-and-now/
September, 2013, AAPC Coding Edge, Managing Post Operative Pain is a Joint Effort
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2013/09/managing-postoperative-pain-is-a-joint-effort/
February, 2011 AAPC Coding Edge, Understand Payer Guidelines to Keep Up-to-date with Anesthesia
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2011/02/understand-payer-guidelines-to-keep-up-to-date-with-anesthesia/
August, 2009 AAPC Coding Edge, Draw a line between Moderate (Conscious) Sedation and Monitored Anesthesia Care
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2009/08/draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
www.aapc.com/blog/37862-quality-reporting-for-anesthesia-services-then-and-now/
September, 2013, AAPC Coding Edge, Managing Post Operative Pain is a Joint Effort
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2013/09/managing-postoperative-pain-is-a-joint-effort/
February, 2011 AAPC Coding Edge, Understand Payer Guidelines to Keep Up-to-date with Anesthesia
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2011/02/understand-payer-guidelines-to-keep-up-to-date-with-anesthesia/
August, 2009 AAPC Coding Edge, Draw a line between Moderate (Conscious) Sedation and Monitored Anesthesia Care
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2009/08/draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/
November/December 2005 Nancy Maguire's Coding & Billing Expert
Anesthesia Billing for CRNAs’
A timely topic if ever there was one! This issue continues to be a source of confusion to physician offices, billers, hospitals, and insurance companies, too. A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who is an anesthesia specialist and may administer anesthesia independently or under physician “medical direction” or “supervision.” CRNAs’ have been practicing in the United States since the civil war, and were the first nursing specialty to be accorded direct reimbursement rights under the Medicare program when President Ronald Reagan signed the Omnibus Budget Reconciliation Act of 1986 (OBRA), which included direct reimbursement for CRNA’s under Medicare in Section 9320.
Reporting claims for a CRNA with carriers other than the Medicare program can be confusing, and there are several different issues for each practice to consider before determining the correct method. This article will address considerations such as employment status, state scope of practice laws, and carrier recognition – as well as the practical considerations of how to effectively file claims and calculate separate charges, when necessary.
One of the most important aspects to consider is who employs the CRNA. A 2003 survey conducted by the American Association of Nurse Anesthetists (AANA) shows approximately 37 percent of practicing CRNAs are employed by a physician group, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. In the majority of cases (53%), either the CRNA is employed by a group or is an independent contractor.CRNAs and those who employ them must accept assignment on their claims; however, filing rules for the various insurance carriers differ. According to the AANA, there are only 36 states that directly reimburse CRNAs under Medicaid; approximately 38 Blue Shield entities provide direct reimbursement to CRNAs, and approximately 22 states that mandate direct private insurance payment to CRNAs. That leaves a number of states out of the loop!So let’s try to clear this up…
CRNAs may be self-employed and bill for their own services. State scope of practice laws determine whether direction or supervision of a CRNA by a physician is required.In January, 2004, the American Society of Anesthesiologists (ASA) published a complete list of state requirements on their web site entitled, “The Scope of Practice of Nurse Anesthetists.” Although several states allow surgeons to supervise a nurse anesthetist – they are billed as “non-medically directed.” A surgeon may not wear two hats and collect payment as both the surgeon and the medically directing physician.
When filing claims through the Medicare program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are revenue neutral - meaning reimbursement is equal to the same amount. For example, when medical direction modifiers “QK and QX” are reported (see table below), reimbursement is divided equally (50% and 50%) between the physician and the CRNA.When a CRNA is non-medically directed, full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems.Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!
Many private insurers expect CRNA services to be billed under the anesthesiologist, on one line of the claim form. Reporting separately may result in a claim denial or improper payment. An additional confusion, since many practices generally equally split the full amount of the bill between the physician and CRNA, is that the claim is viewed as a duplicate. Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.
One way to avoid confusion when you must bill two claims, i.e. to collect a Medicare secondary balance, is to charge different amounts for the physician and CRNA. For example, in our practice we assigned 70% of the conversion factor to the physician and 30% to the CRNA; however, your practice may choose to assign a different value. Assigning different values when claims must be split helps identify and separate the services of the physician and the CRNA, as well as decrease odds the claims will be mistaken as duplicate.It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!
How can you tell when to send separate claims? One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNA’s. To receive payment from carriers that require two claims, the CRNA must have a valid provider number and have reassigned their benefits. It is important to ensure the provider number is valid before the CRNA begins working. Many practices lose revenue by their inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA whose number is not yet in place, such as temporary providers. Although short-term contract or temporary CRNA’s are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.
In most instances, CRNA’s are prohibited from using the Q6 modifier to receive payment, since by definition the modifier indicates the service was provided by a “physician.” However, as to be expected in the anesthesia world of billing, there are no “absolutes!” Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6 modifier by CRNA’s.Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.
When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors. First, the method of reporting claims. As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services. Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed”
rule to come into play. In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service.”
The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNA’s.According to the January, 2005 Ohio Job and Family Service Physician Handbook, "Services of a hospital employed CRNA/AA are included in the facility." In some cases, Medicare offers small hospitals that employ only one CRNA a "pass through" billing option. When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital.
It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction. No time is allowed for any of the concurrent cases.You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.
The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.Obtain state guidelines for each major carrier - Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.
QZ: (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.
QX: (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction.
QK: (physician modifier { used in conjunction with QX modifier} -pays 50%) Medical direction of two, three or four concurrent procedures
QY: (physician modifier { used in conjunction with QX modifier} -pays 50%) MD is medically directing one CRNA
AD: (physician modifier { used in conjunction with QX modifier} -pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures
Q6:(physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source: HCPCS, 2005
By: Kelly Dennis, MBA, ACS-AP, CPC
Anesthesia Billing for CRNAs’
A timely topic if ever there was one! This issue continues to be a source of confusion to physician offices, billers, hospitals, and insurance companies, too. A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who is an anesthesia specialist and may administer anesthesia independently or under physician “medical direction” or “supervision.” CRNAs’ have been practicing in the United States since the civil war, and were the first nursing specialty to be accorded direct reimbursement rights under the Medicare program when President Ronald Reagan signed the Omnibus Budget Reconciliation Act of 1986 (OBRA), which included direct reimbursement for CRNA’s under Medicare in Section 9320.
Reporting claims for a CRNA with carriers other than the Medicare program can be confusing, and there are several different issues for each practice to consider before determining the correct method. This article will address considerations such as employment status, state scope of practice laws, and carrier recognition – as well as the practical considerations of how to effectively file claims and calculate separate charges, when necessary.
One of the most important aspects to consider is who employs the CRNA. A 2003 survey conducted by the American Association of Nurse Anesthetists (AANA) shows approximately 37 percent of practicing CRNAs are employed by a physician group, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. In the majority of cases (53%), either the CRNA is employed by a group or is an independent contractor.CRNAs and those who employ them must accept assignment on their claims; however, filing rules for the various insurance carriers differ. According to the AANA, there are only 36 states that directly reimburse CRNAs under Medicaid; approximately 38 Blue Shield entities provide direct reimbursement to CRNAs, and approximately 22 states that mandate direct private insurance payment to CRNAs. That leaves a number of states out of the loop!So let’s try to clear this up…
CRNAs may be self-employed and bill for their own services. State scope of practice laws determine whether direction or supervision of a CRNA by a physician is required.In January, 2004, the American Society of Anesthesiologists (ASA) published a complete list of state requirements on their web site entitled, “The Scope of Practice of Nurse Anesthetists.” Although several states allow surgeons to supervise a nurse anesthetist – they are billed as “non-medically directed.” A surgeon may not wear two hats and collect payment as both the surgeon and the medically directing physician.
When filing claims through the Medicare program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are revenue neutral - meaning reimbursement is equal to the same amount. For example, when medical direction modifiers “QK and QX” are reported (see table below), reimbursement is divided equally (50% and 50%) between the physician and the CRNA.When a CRNA is non-medically directed, full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems.Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!
Many private insurers expect CRNA services to be billed under the anesthesiologist, on one line of the claim form. Reporting separately may result in a claim denial or improper payment. An additional confusion, since many practices generally equally split the full amount of the bill between the physician and CRNA, is that the claim is viewed as a duplicate. Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.
One way to avoid confusion when you must bill two claims, i.e. to collect a Medicare secondary balance, is to charge different amounts for the physician and CRNA. For example, in our practice we assigned 70% of the conversion factor to the physician and 30% to the CRNA; however, your practice may choose to assign a different value. Assigning different values when claims must be split helps identify and separate the services of the physician and the CRNA, as well as decrease odds the claims will be mistaken as duplicate.It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!
How can you tell when to send separate claims? One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNA’s. To receive payment from carriers that require two claims, the CRNA must have a valid provider number and have reassigned their benefits. It is important to ensure the provider number is valid before the CRNA begins working. Many practices lose revenue by their inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA whose number is not yet in place, such as temporary providers. Although short-term contract or temporary CRNA’s are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.
In most instances, CRNA’s are prohibited from using the Q6 modifier to receive payment, since by definition the modifier indicates the service was provided by a “physician.” However, as to be expected in the anesthesia world of billing, there are no “absolutes!” Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6 modifier by CRNA’s.Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.
When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors. First, the method of reporting claims. As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services. Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed”
rule to come into play. In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service.”
The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNA’s.According to the January, 2005 Ohio Job and Family Service Physician Handbook, "Services of a hospital employed CRNA/AA are included in the facility." In some cases, Medicare offers small hospitals that employ only one CRNA a "pass through" billing option. When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital.
It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction. No time is allowed for any of the concurrent cases.You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.
The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.Obtain state guidelines for each major carrier - Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.
QZ: (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.
QX: (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction.
QK: (physician modifier { used in conjunction with QX modifier} -pays 50%) Medical direction of two, three or four concurrent procedures
QY: (physician modifier { used in conjunction with QX modifier} -pays 50%) MD is medically directing one CRNA
AD: (physician modifier { used in conjunction with QX modifier} -pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures
Q6:(physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source: HCPCS, 2005
By: Kelly Dennis, MBA, ACS-AP, CPC
MGMA E-Connextion, Issue 86, October 2005
Internal audits
Many practices are too busy with day-to-day work to keep track of how often they should conduct internal audits. However, if your practice has a compliance plan, it generally outlines the required audit frequency. Do you know what your compliance plan requires?
If your anesthesiology practice is using the standard compliance plan outline published by the American Society of Anesthesiologists in Compliance With Medicare and Other Payor Billing Requirements, your practice is required to review pre-submission (claims reviewed before filing to the insurance carrier) on a quarterly basis, and post-submission (claims reviewed after filing to the insurance carrier) at regular intervals, such as semiannually.
Having anesthesia records available as you start your internal audit can make an internal audit easier. If anesthesia records are not available, obtain them from the hospital.
An internal audit is simply an objective review of the anesthesia services billed to monitor the accuracy of claims. It
should be performed by a qualified employee – such as the office administrator, manager, certified coder (other than the employee who coded the services), the compliance officer, a physician, or a combination. Each practice determines the number of charges or percentage of claims to be reviewed for each provider. It also determines how to make appropriate corrections and, depending on the internal audit results, whether to contact legal counsel. Although the standard compliance plan requires the practice to undertake all claims monitoring with legal counsel, the practice may modify the plan to require legal counsel consultation only during external audits.
A simple pre-submission review should compare the codes and modifiers billed with the documentation on file. Because the auditor reviews this information before submitting the claim, corrections are made during the review process and corrective actions should be taken and conveyed to staff. For example, a review determined the coder mistook “TKA” for a total knee arthroscopy (01400 base value - 4) rather than total knee arthroplasty (01402 base value -7). The practice must take several corrective steps:
1) Change code, if applicable.Different physicians may be using different acronyms;
2) Ensure acronyms in your practice are clearly defined; and
3) Request a report of 01400 and 01402 claims filed within the past 18 months to verify accuracy.
Post-submission review is more complex and should include a review through resolution. Choose a date within the past six months, and in addition to checking codes and modifiers used, review payment processes to ensure correct reimbursement and appropriate adjustments were made. Each practice should know exactly what payment to expect. Medicare pays by location and the amount is standard; other payers may be contracted using various amount and time calculation techniques so a matrix of expected reimbursement is helpful.At the very least, a form listing annual expected amounts is necessary.
An important area to review is concurrency and documentation of medical direction criteria. Depending on your software concurrency reporting capabilities, it may be necessary to review an entire day of concurrency if your practice includes residents, certified registered nurse anesthetists, anesthesia assistants, or student registered nurse anesthetists. It is important to understand that concurrency calculations must include all patients, regardless of
insurance. While some carriers allow a combination of up to four concurrent cases, graduate medical rules differ and allow up to two cases when residents or SRNA’s are involved.
Whether conducting a pre- or post-submission review, keep documentation of all steps taken in a compliance file. Even if your practice only reviews once a year, make certain the time frame agrees with the written compliance plan. The adage, “It is better not to have a compliance plan, than to have one and not follow it,” is particularly true for anesthesia practices, as anesthesia billing rules are often vague and ambiguous.
By Kelly D. Dennis, kellyddennis@attglobal.net, MGMA member and president, Perfect Office Solutions, Leesburg, Fla.
Internal audits
Many practices are too busy with day-to-day work to keep track of how often they should conduct internal audits. However, if your practice has a compliance plan, it generally outlines the required audit frequency. Do you know what your compliance plan requires?
If your anesthesiology practice is using the standard compliance plan outline published by the American Society of Anesthesiologists in Compliance With Medicare and Other Payor Billing Requirements, your practice is required to review pre-submission (claims reviewed before filing to the insurance carrier) on a quarterly basis, and post-submission (claims reviewed after filing to the insurance carrier) at regular intervals, such as semiannually.
Having anesthesia records available as you start your internal audit can make an internal audit easier. If anesthesia records are not available, obtain them from the hospital.
An internal audit is simply an objective review of the anesthesia services billed to monitor the accuracy of claims. It
should be performed by a qualified employee – such as the office administrator, manager, certified coder (other than the employee who coded the services), the compliance officer, a physician, or a combination. Each practice determines the number of charges or percentage of claims to be reviewed for each provider. It also determines how to make appropriate corrections and, depending on the internal audit results, whether to contact legal counsel. Although the standard compliance plan requires the practice to undertake all claims monitoring with legal counsel, the practice may modify the plan to require legal counsel consultation only during external audits.
A simple pre-submission review should compare the codes and modifiers billed with the documentation on file. Because the auditor reviews this information before submitting the claim, corrections are made during the review process and corrective actions should be taken and conveyed to staff. For example, a review determined the coder mistook “TKA” for a total knee arthroscopy (01400 base value - 4) rather than total knee arthroplasty (01402 base value -7). The practice must take several corrective steps:
1) Change code, if applicable.Different physicians may be using different acronyms;
2) Ensure acronyms in your practice are clearly defined; and
3) Request a report of 01400 and 01402 claims filed within the past 18 months to verify accuracy.
Post-submission review is more complex and should include a review through resolution. Choose a date within the past six months, and in addition to checking codes and modifiers used, review payment processes to ensure correct reimbursement and appropriate adjustments were made. Each practice should know exactly what payment to expect. Medicare pays by location and the amount is standard; other payers may be contracted using various amount and time calculation techniques so a matrix of expected reimbursement is helpful.At the very least, a form listing annual expected amounts is necessary.
An important area to review is concurrency and documentation of medical direction criteria. Depending on your software concurrency reporting capabilities, it may be necessary to review an entire day of concurrency if your practice includes residents, certified registered nurse anesthetists, anesthesia assistants, or student registered nurse anesthetists. It is important to understand that concurrency calculations must include all patients, regardless of
insurance. While some carriers allow a combination of up to four concurrent cases, graduate medical rules differ and allow up to two cases when residents or SRNA’s are involved.
Whether conducting a pre- or post-submission review, keep documentation of all steps taken in a compliance file. Even if your practice only reviews once a year, make certain the time frame agrees with the written compliance plan. The adage, “It is better not to have a compliance plan, than to have one and not follow it,” is particularly true for anesthesia practices, as anesthesia billing rules are often vague and ambiguous.
By Kelly D. Dennis, kellyddennis@attglobal.net, MGMA member and president, Perfect Office Solutions, Leesburg, Fla.