Welcome, everybody. We're going to get started. I know some are trickling in here, but welcome to our session. My name is Dr. Matthew Grierson. I am in private practice in Seattle, Washington, and I'm chair of the Reimbursement and Policy Review Committee here for our academy. I just have a couple of announcements here before we get started. Number one, please silence your phones. For all sessions except workshops, the audio recording is taking place within the room for people who are watching afterwards, so just please keep that in mind. Also, we have evaluation forms. Please make sure to complete those. It helps us for next year to develop better programming. I would remind you to visit the pavilion, but I think it just closed. And then finally, just remember to claim your CME at the end of today's session. I am about to introduce Linda Duckworth. She has over 30 years' worth of experience in healthcare, ranging from practice management and revenue cycle analysis to audit and compliance. In recent years, her focus has been on large-scale appeals and aiding physicians and groups who have found themselves at odds with the government and other payers. She's assisted clients with meeting their corporate integrity agreement obligations, worked through diversion agreements, helped those who have been accused with wasteful billing practices, and she's been involved in defense teams in healthcare fraud investigations. She's been a featured speaker for physician specialty societies, as well as a conference presenter for compliance and coding associations. She is a former National Advisory Board member for the AAPC, and she has written articles for billing, coding, and compliance publications. Linda oversees the technical review of work products for her firm, Ventra Health, and continues to perform audits that are educational and actionable. We're going to learn a lot from her today, so please join me in welcoming Linda. Thank you. Okay. We'll just jump right in here. Quick disclaimer on this. Educational purposes only, and any references to CPT, you know, AMA still owns that, so we don't want to make this any kind of a substitute for the CPT manual, so just kind of putting that out there for you. Here's my email address, and it's also at the last slide, and so when we're done with this and we all go back to our homes and you want to reach out to me, you are more than welcome to email me. I'm just going to ask that you say, hey, I heard you at AAP Menard, and then that way I kind of know where your questions are coming from, so you're certainly open to do that or welcome to do that. So here's some of our goals today. I want to make you aware of what triggers audits with these payers, and I can really base a lot of this on my experience over the last several years when I've been working with physicians and with groups. We want to talk about documentation goals and what can you do to really bolster your record from a coding perspective or from an audit perspective but yet not be writing books, so we want to get away from that. I want you to be able to anticipate some challenges you might have if you go under payer audit, so what are those things that are going to be a real problem or a hurdle for you to get over in case your records are requested? We want to create an audit plan with some safeguards, too, so we'll talk about that. So whether you're actually employed in a large university setting or if you're an independent person that maybe you're just working under a management service organization like we see a lot of times with our SNF providers, I hope that this is going to speak to everybody. So even if you're in that larger setting, you go back and you ask the people that are your compliance department, your audit team, your billing manager, and you say, hey, I want to know what is our policy or our procedure when it comes to some of this correspondence coming in from the payers. When are you going to make me aware that this has come into the billing office and it has my name on it? So it's important that they know that you want to be aware of this activity that might go on behind the scenes. You want to be involved with that. You want to know that that's going on. So to talk about some of the triggers here, it's data driven. Almost always it's data driven. Now certainly you can have somebody filing a complaint, whether that's going to be a patient, is it going to be maybe a disgruntled employee? So that certainly could happen, too. But mostly what we see is this being data driven. And these payers have very sophisticated software to go out and look at you and compare you to your peers and see where you are compared to them. And if you kind of fall outside of that, then you might become a target. I hate to say target, but that's kind of what you become. So maybe we were talking about frequency of services per patient. Now that could be procedures or it could be maybe subsequent E&M services, especially in the SNF. We see that to be a real problem. That's probably one of my biggest, my introduction to SNF actually happened to be a physician who was in trouble for E&M coding over $600,000 were going to have to be repaid back to Medicare. We were able to go back in and save him about $240,000 or $50,000, but he did end up having to pay back around $400,000 on that. So on those subsequent E&M visits in the SNF, are they happening too frequently? Are those providers in there seeing them every single day regardless? So that's kind of what I'm talking about there. Maybe it's high volume on your procedures, E&M levels. Are you too high? Are you too low? Because both of those could actually get you in trouble. So coding, undercoding, and you're thinking that's a safe place to be, just kind of slide in under the radar, maybe not necessarily. The 214 on your office visits, you know, what do you look like compared to your peers? Same thing in your coding in the SNF, or if you're in an inpatient rehab, what do you look like? So if you're sticking out like a sore thumb, you might be inviting that payer in to come and look at your records. Overuse of payment affecting modifiers, that's another one that they like to target, 25 and 59 are huge. Even the Office of Inspector General had 25 on their radar for quite a while, and they were really going after the overuse of that and getting those separate E&Ms paid for in addition to procedures when they probably should not have billed them in the first place. So maybe it's a high-cost service, you've got a lot of those going out the door, spinal cord stimulators, those kinds of things. The history of abuse as maybe the payer has actually identified those with some of their audits. This gentleman's asking that in a smallish town setting that they had another provider who just got hit with some fraudulent accusations or whether it was founded or unfounded, I'm not sure. So he's saying, do you think that that would prompt then a review of those around them in the geographic area? And I would say on that right there, isolated case, probably not. I wouldn't say necessarily your geographic area was like, oh, well, it's going on in Marietta, Ohio, down the street, I bet it's on the other street too. I wouldn't think so, that's a good question, but I haven't seen anything like that happen before. Winds may shift during the storm. So the other thing we wanna be thinking about is that maybe this payer is going after that provider on maybe that initial visit, everybody's a big fan of the 99223 in that like inpatient rehab setting or in inpatient rehab or in a traditional acute setting. And what ends up happening is your payer saying, hey, this is what you look like, your coding pattern, but then they get in there and they get ahold of your records. And now all of a sudden, maybe it's not so much the coding level that's gonna get you into trouble as much as it might be that you are billing this as a split shared with your nurse practitioner or your PA, and you're not getting that subsequent portion of that documented well. Those attestations. So now all of a sudden, it kind of shifts into a different direction. And it might expand that scope if they see a bit of a pattern in there. Same thing with your teaching physician. So if you're an attending physician, gotta make sure that you get that on there. Otherwise, what started out to be one thing ends up being a much bigger or broader issue. We talked about that 309 on those frequencies. The one that I had, like I said, I was working with the provider over $600,000 because it ended up being an extrapolation on that one. So Medicare actually targeted him for his overuse possibly of that 309 code. But then they got in there and then that's when they were saying, well, we don't even think you should have seen the patient at all. So it became this whole frequency issue because you go back to that LCD where it talks about frequency in the SNF setting. And so we started out with possible over-coding and we went from possible over-coding to not medically necessary. And I gotta tell you, the documentation was his downfall. It was horrible, absolutely horrible. And I was trying to help him. I'm like, I'm shrugging my shoulders and I don't know why you saw that patient that day. So that's what we're looking at as far as these things start to shift and it becomes more of a storm. You're in drug screens. So they're looking at that. Are you coding them? Or are they're happening over, the frequency is gonna be a problem. And then they get in there and it's not just the coding, but then it starts to just snowball. And then we look at medical necessity. Are we getting those risk assessments done? We're not getting the lack, there's a lack of specific orders and then they over-code them based on the drug classes and all of that. Now, I'm not an expert in this area with the urine drug screens. My coworker is and she just finished up a big project on this. And I did the technical review of it and just making sure the language was all there. But I'm reading this and I'm hearing her talk about it. And so this is another one of those where you think it starts out here, but it ends up in a whole different direction. So Medicare, I spent a lot of time with Medicare. I hate to pick on them, but that's where probably most of my time is spent is with Medicare. And so some of their monitoring programs now that CERT has been around, that first one for many, many years. I can remember this coming up, I'm gonna say over 20 years ago. If you get something from CERT and this will probably come in from your billing office. So it'll come into the billing office and they're gonna request for your records. And CERT really is what it's supposed to do is it's supposed to be looking at your local MAC. So your Medicare Administrative Contractor. So that's gonna be your CGS, your Palmetto, your Novitas. So they wanna make sure that they're paying these claims correctly. So they're looking at it in all different levels. But one of the pieces of that is making sure also that that documentation is supporting the code and then it was paid correctly. So they're gonna ask for your documentation. You don't need to be worried about this, okay? It's a random selection, usually one case. That's it. So don't get real shook up about it. Now, you always wanna know about that, that Medicare's looking at your notes. But there's nothing to get worried about on that one. So CERT's not a big deal. A CBR is the next one, eh, kind of a big deal, okay? So when you get this, what it's gonna tell you is that, again, here's what your patterns look like up here versus or compared to those that are in that same enrollment category. So physicians that are of the same specialty with this code, with this procedure, with this modifier, here's what you look like. And what it'll say is no action is needed or no response, should really say no response is needed at this time. However, they will conclude that by saying, we encourage you to do a self-evaluation of this. So make sure that the way you're coding is correct in your documentation there. It's a little bit of a warning shot. So if you get that, don't just go, oh, look, it said we don't need to do anything. So whether you're gonna do that internally, you're gonna reach out to someone and say, hey, maybe we should have you go in and look at 20 of our whatever it may be that Medicare's coming after us on or that has told us that we're maybe coding incorrectly. That's what you need to do. I encourage you to do this. And then this, again, this will probably come into your billing office. So I know of somebody here a few months ago, it went into the billing office and since no action was required, it got put on a shelf. And the provider was never made aware of it. So that's one of those you go back and say, maybe with your billing company or whoever you're working with, if we get these kinds of things, what are you doing with this? Because we don't want it just to sit there and collect dust and nothing ever take place. So it's important that you're getting that. Now, if there's no change in your patterns, what'll happen is, now maybe you self-evaluate and you're thinking, I've got an explanation as to why I'm doing more procedures. Well, because maybe I choose to do only procedures. I'm interventional only, I don't see patients, I don't do anything else like that. I just do the procedures. So my numbers are gonna be higher than my peers. And guess what? I'm good, my documentation's good, my coding's good, good for you. Same thing you can maybe explain away with your E&M levels. Maybe it's because you love the train wrecks. You love the train wrecks. And so your pattern might look a little different than someone else. So maybe that's fine. And if it is, you need to feel good about that. And then you don't need to respond. And you don't need to take other actions with it. Now, if you don't do that and the patterns stay the same, it very well could be that you end up being referred over to the Target Probe and Educate program. Now, this only came out about four or five years ago. Carolyn, 2017, I'm thinking is maybe when that went live, right? 2017. And if this happens, this is definitely something that you want to know about and you wanna be involved with. Well, you're gonna have to be involved with it. I guess we'll say that. They're gonna look at 20 to 40 of your claims. It's gonna be prepaid. So they're gonna come tell you, here's the claims that we're gonna suspend these, we're gonna hold them. Then you're gonna turn in your documentation. And then once they collect their 20, 30, 40 that they're looking for and they're gonna evaluate, you're going to have a meeting with one of their nurse reviewers. And this person's gonna go over your documentation and they're going to give you tips. They're gonna say, well, you're falling short here. I'm not seeing that. It's not made clear. So it depends on what the result of that is. And so if everything's good and they just look at your documentation and they're happy with it and they're thinking, you know what, great job. Coding's there, documentation's there. They're gonna let you go and you're done. Now, if they come back in and they're like, we're gonna say that you had a 30, 40, 50, 60% error rate, which could happen, okay? I've seen it happen. What'll happen is then they're gonna do that education. Then they're going to put you on a second round and they're gonna make sure that you've now taken the education to heart, you've improved, whether the coding or the documentation, then they're gonna do a second round review. Same process. What does it look like? Oh, it's good. Then we're gonna leave you be. You're not quite there. We're gonna have another telephone call. So that's that TPE and it just kind of keeps on going. And if you get to that third round and you're still not there, then it could be that they would refer you on to the next level of review, which is definitely a place you would not want to be. Quick question here, yeah? So if you had a SIR and said no action required, you look at the stuff and you say, I do need to make some changes. You make the changes, are you sending the response? No, no, no. If you look at that, you get that TPE, or excuse me, you get that CBR and it says that you don't have to respond at this time. And then you go in and say, oh, it looks like we do need to maybe make some corrections and you do, and then you're being proactive in that. So no, just adopt those good practices and then move forward. So you're gonna be fine. Good question there. So when they say in person, these are telephone calls. Okay, so the question is, are we talking about changing going forward or are we going backwards? Well, there's two schools of thought on that. So if you went in or you hired somebody to come in and they say, for the last three years, this procedure that you've done, the documentation absolutely does not support it. And then at that point in time, you would want to get a hold of probably a healthcare attorney and say, do I have a self-disclosure? So I mean, that's like an extreme case, but it could be. Otherwise, this is just going forward. You know, we just need to improve, let's just fix what we know that we need to fix and let's move forward, okay? So that's kind of how this goes, and like I said, that in-person is a telephone call and that's what that's about. And again, you need to be aware of it, you will be made aware of it, because they're going to want you in on that call. Not a bad idea that you have somebody that maybe is your coding manager, somebody who's really savvy, really savvy with coding, sits in on those calls and listens in because you absolutely have a right to do that. You would also have a right to have an attorney sit in on that if you would want to. But you want somebody savvy because then you've got this physician, you as a physician, saying, well, let me talk about this clinically, but then you also have the coder asking like coding talk questions. You know, so not a bad idea to involve them on this. So now if you get something from the UPIC, so the Unified Program Integrity, okay? So this comes into your practice, comes into your billing office. This is something that you 100% do not want to go at alone. This is the time, this is the letter, the type of communication that you do need to be calling, in my opinion, a healthcare attorney, okay? Because the purposes of the UPIC, you have been referred to the UPIC. So maybe it's because of that comparative bill, or no, excuse me, not the comparative, the targeted probe and educate, you went through the three rounds, they were still seeing problems, so they're going to refer you on. Or maybe, again, it could be a disgruntled employee or something like this that is going to be accusing you of some inappropriate billing practices. So that's what this is really about. So it's to investigate instances of suspected fraud, waste, and abuse. So I've seen physicians, the first one, like I said, kind of keep going back to the 600,000 on the SNF, right? Got this. Well, other communications, and they just kind of ignored them. But then they got the UPIC, and then that's when the troubles really started, because then they really didn't know what they were doing, they didn't know what records to submit, and it just snowballed and really got out of control. So if you see anything coming in from that UPIC, that is a very concerning situation, and you do need to be calling for help at that point in time. You certainly don't want to see that communication sitting in the billing office and not be, and left unattended. So now responding, here's the interesting thing, responding to some of these. I want to say, in my experience, number one problem with these audits with your payers, or appealing those results from an audit, right there, not submitting the documentation that you need to support the fact that you did it, that it was medically necessary, and that it was coded correctly. Number one. And it just seems simple. So a lot of times you get these requests for records coming into your office, and you hand it over here to a clerk, some of your medical records clerk. And they look at it, and it says, oh, we need to do the progress note for that day, or the procedure note. And then they go, and then they print it off, and they load it up, or they upload it now electronically, whatever that may be. And they're not looking to see, do we have everything we need to make sure that it goes through? So number one, I had 1.6 million on EEGs for an independent testing facility, and we're looking at this, and it's all about medical necessity. So when Medicare wrote this up, it kept saying, not medically necessary, not medically necessary. They really failed to come in and say, oh, by the way, you're billing the technical piece of this, and that's what we need you to prove. So after I'm sorting through this, it finally dawned on me, I'm like, wait a minute. You guys are the testing facility, the technical piece of this, but what did you turn in? The physician's interpretation and report, which is great, because that supports his or her billing, but it doesn't do anything, really, for that facility. So I'm like, oh my gosh, you need to download. You have to download this. And it was, honestly, it was a big deal, because they were the video, so it was a pain. And they said, do you realize how long that's going to take us to download? I'm like, you're on the hook for 1.6 million. Who cares how long it takes you? You need to do this. But then to make sure that we were getting everything, we went back in and said, okay, now we've got that piece of it, but let's go ahead and get the medical records from the ordering physician. Let's get the orders. Let's do everything we can, because we want to make sure that we're getting it all. And so, again, number one, not getting the records that we need. Complete versions, kind of the same thing, making sure that we're getting the best version of it. If you print off a record from your electronic medical record, does your signature print off? Does the two patient identifier requirements, you know, does all of that print off? So if we're going to really print these off and then upload them, we've got to make sure that that's the version that's going to go into that payer. Same thing about an unsigned copy, too, that we've seen where it gets sent over immediately, you know, from a facility and uploaded into your ER back at your office, and it happens to be the unsigned version. Well, that's going to be a real issue, sticking point with Medicare, and they're going to come back, and it's an easy way for them to deny a claim a lot of times. Appeals. I want you to keep in mind, if you're going to appeal something, whether it's just a single claim or whether it's a big number, you know, 30, whatever, 40, you only really have two times to submit your records. So if you goof it up the first time because you didn't get the orders in there, you don't have the medical necessity in there, but yet it could have been maybe found in a progress note, you've already wasted one opportunity because we get to do a redetermination, and then if that's unfavorable, it goes to the reconsideration. And then you get in there, and you're like, oh, gosh, you know, if we would have just sent this or that record. So now we get to add those in there, and we go back through the process again. And then if you feel like you're being really wronged on this, and then you realize, oh, we should have sent another record, well, if you get to this third level, which is your administrative law judge, it's a rare, rare, rare occurrence that they let you add records in at that level. So we always want to be thinking about our first attempt should be our absolute best attempt. Then we get one more attempt through this. So it's so important that whoever's doing your release of information is savvy on this, and they know what's needed to support a code or that medical necessity. And then that's why I've got that little eight ball up there saying, you know, if you go at this alone, and you're uploading these records, and then you don't maybe keep copies, especially on the bigger, you know, the bigger submissions, the 20, 30 cases, then you reach out for help. And you reach out to somebody like myself, and I'm like, okay, well, what did you submit? You know, how did you all end? And we feel like we're behind the eight ball, and we're trying to get out from behind it just to help you there. So responding, put the right person, because really, we can't make changes. So we don't really want to be making changes to our medical records, but we want to go back in and look and confirm maybe the coding or the claim accuracy, the place of service. We want to make sure that that's correct, because if you're doing that in the outpatient setting, but they accidentally billed it with an office setting, you could have an overpayment, you know. So you really want to make sure before you send all of this in that you did it right the first time. Look back there and make sure that you've got the physician at teaching hospital attestations or the split shared. And again, I don't want you adding information to the record. I want you to know what's going to happen when the records get submitted, right? So at least you're not being surprised by this, but you should not be adding that information six months down the road. I mean, that would be completely inappropriate, so I want you to be really careful about doing that. Submit your records to those LCDs and NCDs, so those of you in the SNF setting, possibly. Those of you that are doing procedures, you know, are you meeting all of that criteria? Do you need to get maybe notes from other physicians, referring physicians or something along that line to support everything that you've done? So maybe you need to look at that. Is there payer-specific policies? Now, this has happened, too. This has happened, where you submit the records, especially like to Medicare, and you go through that first round, and it's unfavorable. So then I've seen where they've came back in, the providers have came back in, and they've added things to the record, which is a huge no-no, huge no-no. But then what you need to know is those records, the original submission gets forwarded, and now you're submitting an altered copy, and that's going to be a real problem for you, okay? So please don't be thinking, well, just go back, just write it down, just write it down, pat it. No, we can't do that. Totally inappropriate. So do be careful with that. The other things that we have to look at is the less than obvious. So if I've got somebody, you know, office visit, and they're saying that the October 1st labs and images were ordered, and now with our big changes on E&M and this... So those of you that are in the office setting and you've been working with the E&M changes now for a couple of years, the rest of you, no matter what your setting is, you're going to the new E&M guidelines at the first of the year. So we start talking about all of the unique tests for the data points, and so in your medical record, if you're just saying that we reviewed this, I don't know how many from whether I'm a coder or an auditor or whatever, how am I going to give you that data credit if you don't tell me exactly what it is that you were looking at? So I kind of need to know each individual test. So that's something new for you, that's a way that you can improve your documentation. So if you'll list those out so I know exactly what it was that you were looking for. Another thing that might catch us, that if you're in a setting that you're doing the discharge summaries, and I can't... There's no evidence that you had a face-to-face with the patient because there's no exam, or you didn't make comments, I discussed with the patient, so I know you had the face-to-face. What are other areas of the notes, the chart could I go after? Well sometimes there's a separate progress note, and I can go pull that, there you go, there's an exam on that. So that's where a coder can help you out with this and say, oh wait a minute, Dr. G, I don't see your exam or any evidence of a face-to-face. So they know to go look for those other records. So getting them to help you with that will be great. Other things we might look at, maybe nurse's notes. So maybe we didn't do the best job in saying exactly why we're back in here seeing the patient today, but we can go to the nurse's notes. Is it going to help you? Is it not going to help you? I don't know for sure, but we definitely pull them. So where I can see that the nurse made a comment at 7.30 in the morning, they thought that the patient was maybe not exactly herself, and they were concerned about that. But then my physician went in the note a little bit later, and it's not real evident. So maybe that would be helpful, things like that. If you're referring to any other documents, pieces of the chart, those of you on the 95, 97 guidelines, so you're getting those review of systems, past family and social, you're making references to those documents, those need to be printed, and then they need to be sent in with your progress note or your HMP under audit. That's what you're going to need to do. Referral notes possibly from the requesting. On your procedures, imaging when the note omits the levels. So you forgot to put the levels in there that you treated, but one of the ways that you could support that possibly is if you have images of what you were doing there in your needle placement, and that could help you out. Orders, progress note resulting in the decision for the procedure. So maybe your procedure note isn't exactly the most beautiful piece of work. Where's my medical necessity? Well, I've got my office note from a couple days before talking all about that, so maybe that needs to go in. Or records from an ordering provider. I've seen where the drugs are missing, so maybe your lidocaine or your steroid that you're injecting, but I can go to another piece of the note and I can see where it's in there, maybe in my nurse's notes, so I could print that off. So, nurse notes, PT notes relating to failed conservative treatments leading up to those procedures, and I'm going to get into that more here in just a moment. Yeah, so she's asking on E&M if you're doing the time-based, so what do I need to have in there? And it's really, you know, when we were talking about the counseling coordination of care, so I don't know what world you live in right now, but those of us still that are doing the inpatient rehab and the SNF setting is still the 50, greater than 50%. Is that where you are? No, you're over in the office where you just get to count all your time for the day and who cares about counseling coordination of care. So now it's all encompassing. So really, just explain to me why it took you maybe an hour and a half on this one particular case. So was it this extensive record review? Was it going through, you know, your drug database for the state? Was it talking to others? You know, so you just want to kind of, so that I can read it and go, oh, yeah, I could see where that would take you an extensive amount of time. Non-compliant patients, those are time-consuming, correct? So that, you know, you're spending all that time saying, hey, let's go back over, you know, your drug agreement or whatever it may be. So you just want the reader to know what these extra steps were that took you so long to do this. So it's just kind of up to you. So you can place that wherever you want. You can put it wherever you want in your note, wherever it best fits for you. So sometimes I can even pick up on it by reading your history, your interval history. But definitely in your assessment and plan, you know, and those social determinants, so the homelessness and all of that, that's a big buzz thing now that you're hearing about. So we want to see that. But yeah, just those kinds of things that maybe are just going to be more time consuming. Now you get to go out and say, it's not counseling, coordination, and care, but by golly, this is taking me forever. Well, guess what? With the changes, you get to start counting all that time. And those of you that are still over here in the old world, you have something to look forward to January 1st. So you don't have to worry about that counseling, coordination, and care anymore. So you definitely want to clarify any EMR specifics, or maybe that you've got something, terminology that you use that's specific to you. We just had this come up a few weeks ago. We also work with hospitalist medicine. And the question was posed on the NAD. I've always known that to be no apparent distress. And yet somebody said that they had a physician one time said, oh, no, I always mean that they are not actively dying. What? What? You know, so you just want those kinds of things explained so that that reader of your note always knows what you're talking about. Okay, so templated entries. Maybe you're just using these templates, and you're using them, and you're using them. But maybe there's some language in there that you've created that's maybe not necessarily easily recognizable to a coder or an auditor. Illegible signatures. If you have that come up, you're going to need to do a signature log. But anymore, most of what we do is electronic. So you're probably going to be okay. Same thing about if you would have any handwritten notes, a little chicken scratch here or there, you can go back in and type them out verbatim. So maybe you would need to do that. If there's glitches in the medical record, so I've seen lots of glitches in the medical record. Somebody that I was doing a sniff review on a year ago, every one of their vital signs where I needed it for the physical exam still, they were actually being dated a day or two after because it was when the physician put them into the note and not when they were actually taken. And we're like, well, to be technically correct, we can't count them. So you're going to have to explain those kinds of things. Credentials describe the role of the people involved. So what I'm saying is, you know, so if you're going to reach out and say that you had discussions with Susan Smith, who is Susan Smith? Well, come to find out that's the patient's social worker. So you always want to say Susan Smith, the social worker, because especially under the new guidelines, we get to include those kinds of discussions in our calculations. So tell me who these people are. Same thing with the family member. If you are just doing simple family updates and being a kind physician and letting them know what's going on, we're really not going to count that. But if these people are acting as surrogate decision makers on behalf of, make sure I understand that your reader needs to know that through your notes. So why are we going to invest in an audit program? Because think about this. You cannot prove your own work. So I personally think that I do a really good job with writing, whether I'm doing an audit, whether I'm doing the executive report or I'm writing an article, I feel like I'm a pretty good writer. But sure enough, I know better than to think that my stuff can just go without somebody else proofing it with that other set of eyes. So it's an investment. So what is your return? Your return on an investment, whether you have this internally within your own organization or if you were to outsource it, you have somebody coming in unbiased, somebody unfamiliar with your records or the way that you document. So they're almost looking at this as like maybe a payor would. Well, I don't know what that means. I don't know what your acronym means. I don't know when you say that phrase. I don't know what that means. Or we can come back in and say, oh, I know that's going to be a real issue for you. That's going to cause a hurdle. You think that that's a great job of describing it, but it's not. So you really get that fresh perspective in there, and then they can bring up those challenges before the payor. And then also we can kind of treat it as a practice run for that documentation retrieval process, what it looks like before we submit it to the payor. So another thing like an auditor might do, and those of you that are working in this set of codes here, it just kind of baffles me that this has always been part of CPT as far as going in and saying, you know, here we typically on a 307 or a 231, this is a patient who is stable or recovering. Then you bump it up, responding inadequately to therapy. Maybe the patient's unstable or developed a significant complication or problem. This 310 for my SNF people, patient's unstable or may have developed a significant new problem requiring immediate physician attention. And I think that the reason CPT put that in there, because in that world, you can still code from history in the exam and carry the code regardless of what the decision making comes out to be. Well, that's inappropriate. So we still have to be thinking about the medical necessity of this. So I will see people go in, the coders or maybe the internal auditors, and they go, yep, coded correctly, yep, coded correctly. And you come back in with somebody from the outside and they're like, but what about this? You know, what about this? Because Medicare is always going to bring those back into those reports, and that's a big hurdle for us to get over in that setting. So this is why you kind of want to get that fresh perspective on what you're doing to make sure that you can survive some of these audits. So some of the hurdles, unable to determine the status of the conditions. Now, I'm talking to those of you, this is kind of E&M related, so whether you're in the office setting or whether you're in a facility setting of some sort, I need to know the status of those conditions, okay? Because you always want to be thinking that those that are worsening or not at goal, that's the big buzz term now with the E&M changes, at goal or not at goal, stable or unstable. So those that are not at goal or unstable are weighted more than those that are not. So you need to get yourself in the habit of saying patient is not at goal, patient is worsening, patient now says that this is going on and this exacerbation, okay? So those are weighted more. Those are your buzz terms. Those patients are going to be more difficult than those that are the stable or improved, right? So get that in part of your documentation process. So that's an easy way for you to communicate the difficulty of these patients without writing that book. So give me the status. Cannot confirm that you did a personal interpretation of images, so if by chance they're bringing something in from the outside, you're looking at that CD or whatever it may be, and you're making your own interpretation of that, and you're not separately billing for it, then tell me you personally looked at those images, because, again, that is weighted more than you simply reviewing a radiologist report. Big difference, okay? So let me know it's your personal interpretation. Write a little ditty about that. You're not billing for an interpretation and report, but at least make some kind of comment about your interpretation of that for those data points. What will happen, too, is the risk does not align with that AMA table. So that's an important thing we want to look at is that risk. So that's that third piece of that decision-making. Whether you're working in the old world with 9597 or the new E&M office, risk is a big piece of that. So we want to make sure that the risk, and so your auditor is going to come in and say, I'm not getting it. I can't get high risk out of this patient by the presenting problem or your management options. So then another thing, too, we always want to make sure that we're only calculating for E&M or doing our diagnosis coding based on those conditions that were managed, evaluated, and assessed and treated during that encounter. So what we know in my world is with the OIG, the Office of Inspector General, has some requirements that we need to have these compliance plans, right? So we always talk about the seven components of an effective compliance plan, and the one that you really want to focus in on is that conducting an internal monitoring and auditing. So that's what we've been talking about. It's so important that you're doing it. It's important that you invite this into your own personal practice, okay? Don't be telling somebody, I don't want this done, and not being an active participant in it, because you really can get some good information back on it. Now, here's your other warning thing. If you ever get something from a payer and they're looking for copies of your audit plan, compliance plan, serial numbers from your equipment, pictures of your equipment, coding billing policies or procedure manuals, there is something else going on, okay? So that, to me, I would definitely be reaching out to someone else, possibly another health care attorney, and saying, this seems to be a little bit more than a routine documentation and coding audit, okay? So this came up for us three or four months ago with somebody, and we kind of did the whole, oh, I really think you need to call an attorney. So they reached out to us just as consultants to help, and then we saw that, and we were like, oh, oh, oh, oh, oh, oh. And that was the urine drug testing. So that was our advice to them, and then come back and let us help you with that. So when you develop the audit plan, you know, make sure, too, one of the things you want to look at is, like, what do I look like compared to my peers? So you can go ahead and do this. When you get back to your office, you can do this yourself or have somebody help you. It's not difficult to do. You can go get that CMS data. The important thing to know, though, is when you start to do your own little data comparison, you're always doing your apples to apples. So compare coding patterns within your own practice. So maybe you want to look at, you know, look what you all look like compared to one another. The data taken from claims submitted. So this is always important to keep in mind, too. So Medicare tells us with this E&M utilization data. So when you just Google search CMS utilization data, you're going to get it to come up. Okay? And the most recent data we have to work with is 2020. And it's claims submitted. There's no confirmation of claims correctly coded and submitted. It's just how your peers are submitting their claims. The data is based on specialty the provider has enrolled in. Okay? So if you were enrolled in your practice and maybe you're doing inpatient rehab, let's say, but they enrolled you as more of a traditional, like, internal med versus physical med and rehab versus, like, a hospitalist, your data really starts to change. So those that are in the physical med and rehab, look at how their distribution changes compared to the exact same CPT codes with physicians who were enrolled as a different specialty. So you would go back to the people that do your enrollment and credentialing and saying, hey, you know, what do I look like? How was I enrolled again, especially if you've made any kind of changes? So just make sure you're doing your apples to apples on that. Other things. They said you can look at the OIG work plan. What are the things that they want to keep an eye on? What are they going to be targeting? History of abuse. And I already talked about this. Like, incident two. If you all are billing incident two in the office setting, proceed with caution. And this is not an incident two session, so we won't go into a lot of detail. Just proceed with caution on incident two, billing everything that your nurse practitioners or PAs doing under your number. Just be wary of that. We talked about the CBR and the TPE. You can go look at the websites and see what's out there. Hot topics. Denial rates within your own practice. What's going on with that? Why do we have so many denial rates? Follow up on previous issues. You know, so if you have something out there, okay, so you have this piece of paper floating around out there and you've had some kind of an audit, whether it's internal, external, whatever that may be, you need to follow up on that stuff. Don't just set it aside and go, oh, we're going to have to improve on that. And don't act upon it because it could kind of come back and bite you. So like we said, you know, if Medicare is looking for your audit plan, have you had any audits? We want to see copies of that. And then you just sat on it and didn't make the recommended changes or had a rebuttal to the recommendations, you know, that were made. So we want to make sure we follow up on that stuff. Other things. I just listed them here. I'm not going to go over all of them, okay? But other things for you to think about outside of just typical routine coding and documentation. Here's a whole list. I'm putting this out there for you. Maybe you need to look at your advanced beneficiary notices with Medicare. I go pull them when I see that the modifiers were used. I go pull them. I'm like, no, no, this is not right. You know, this is not going to fly. And you probably owe the patient money back if you collected money on those. So these are just kind of things out there that I put. And we've talked about a lot of them right there. But you have the slides. Go home and take a look at the slides if you want to, and you can read through them. I'm just going to say, if you're going to outsource, so you're going to go to a consulting firm or whatever that may be, you're an individual or something, but if you outsource, ask them if they give a sample of their reports. Do you like the way it was constructed? Do you like the feedback that they're giving? Because you want to make sure that they're educational, and you want to make sure you can act on them. So make sure that they're giving you the findings and then the recommendations. So ask for those. We're going to go into the LCD criteria real quick here. I'm going to just kind of show you what I'm talking about. So those of you that are doing the interventional pain procedures, maybe what you want to do is almost consider a checklist from Medicare's LCDs, all the coverage criteria, and maybe you want to think about it as your own internal preauthorization process. So many of our other payers, you have to preauthorize these procedures, and they go through and they say, well, did the patient fail those conservative measures? How long has this been going on? Have they done the PT? And so they have that process, and Medicare doesn't, for these at least right now. So sometimes they do, sometimes they don't. It's really a new deal for them. They've only been doing preauthorizations for a couple of years. So maybe that's something you want to consider. We built within our organization, and like I said, I have a couple of coworkers who are all things pain, so they actually built their own audit, and it's only on coverage criteria. So they're going through pages and pages or a year or two of records and seeing if these patients are meeting coverage criteria. So they just built it, and they built it in Excel, and they go through your medical records, and they're saying the moderate to severe chronic neck pain, and is it axial? So that's the question. And the red ones, the red language you see here are most of their findings. No. Is it present for the minimum three months? Maybe there's multiple pain generators. They tried PT, but I can't link, because you just said they had PT. Well, if they've got foot pain and back pain and chronic migraines or whatever it may be, and then they just tried PT, how do we know that the PT they tried was for the back pain? So that's where this person with this independent review can kind of come back in and say, but you need to be a little bit more explicit in that information. A big thing right now with WPS Medicare are insisting on the word failure. Now, I think that we can get that overturned, but they are saying, you didn't say the word failed, those conservative measures. It's right there in the notes, saying patient got little to no relief, but they didn't fail it. Like, are you kidding me right now? So maybe wiggle that word failure in there if you need to. Unable to identify treatment of radiculopathy, non-facet pathology, pain assessment must be performed and documented at baseline and after each diagnostic. So we're going in there, or your staff, you could have anybody in your office doing this for you, and just, you know what, maybe we need to go back and self-evaluate. So create a little spreadsheet based on that LCD, and then just go through and say, you know, are we meeting it? Are we meeting it? Are we meeting it? And you just go down the line. Medical necessity to confirm validity of the initial before we move on to the second one. You know, what about the minimum of two weeks? Meets the criteria for the first diagnostic and then move on. Must be consistent with positive responses. So anyway, this is just something I encourage you all to do if you're doing the interventional pain procedures and you have these LCDs, go back in and self-evaluate because at least those that we work with, I would say probably 80% value rate. 80%, okay? So under an audit, you're going to have real challenges. Yes, sir? Right. So his question is, when I'm doing that office visit before my procedure and my medical necessity is clearly documented, thoroughly documented in my procedure note, do I need to do the same thing with, or in my progress note, do I need to do the same thing in my procedure note? Yes and no. And I would say a much abbreviated version, but it wouldn't be a bad idea to go in with a line or two that talks about, you know, patient failed conservative, blah, blah, blah, blah, blah, blah. You know, but then we go to your procedure note and there it is. And it's all its glory or the progress note in all its glory. And we can get that, but you know, your, your diagnosis should be there, you know, so that's going to cover it. But certainly under audit, not a bad idea to bring that progress note back into it as well. So just do this, just have them go back in and look at that LCD and pull it out and do a little checklist. Other things we might want to look at what we call is a, like their billing policy too. So we've got the LCD, but there's also a billing article and it'll even go into a little more detail. So don't forget about that. If you are all self-monitoring or evaluating, don't forget that piece of it because then we put in here the deal about conscious sedation. And you wouldn't believe how many times our group is seeing people just saying due to anxiety, due to anxiety, due to anxiety. I'm like every single patient you're doing, they're sedating. And it's always because of one thing. So it's almost like a template, bing, bing, bing, bing, bing. And so we want to be careful about that. So on that sedation, you know, they're saying individual consideration, rare and unique circumstances. So is that what you're doing? Now I can't get into a lot of, about that because it's more of my partners that work with this on a day-to-day basis, but you know, definitely want those clear, those patient specifics clearly in there. So what about advanced care planning? Same process. So are you, if you were over here in a post-acute world and you're looking at those codes for advanced care planning, same process. Go back into the LCD. Because with Medicare, we basically have, sorry, advanced care planning. I think I kind of mixed up my slides here just a little bit. I'm so sorry. This is more on, I'm sorry, this is on the E and M subsequent levels. So I apologize for the sniff. And on this one, you know, there's really four reasons to up that frequency of those visits, subsequent visits in the SNF setting. So the top four are going to be instability or change, therapeutic issues, something's going on that requires a timely evaluation or to request, or a request to address documented medical issues. So I'll tell my SNF providers, you know, if you're having to see these patients every couple of days, then when you do your history, be thinking of explaining it to me. So I'm shadowing you today, and we're going to go back in and see Mildred. It's Wednesday. You saw Mildred on Monday. You know, so you're seeing these patients very, very frequently. So tell me. We stopped outside the room, and you're going to turn to me and say, well, no, I just saw, you know, Mildred on Monday, and she was actually complaining of this wound, and I need to, okay, put it in your record. Put it in your record. So those that you're seeing more frequently make me the reader understand why you're in there at such a frequent interval. So then you can go through and say, you know, is it easy for me to pick up? We're seeing these patients more frequently. Presence of inactive or chronic conditions does not necessarily constitute medical necessity for a visit. So is the medical necessity to the reader evident? That's what we want that fresh perspective to look for. Medical necessity must exist for each visit and not really be driven by group visits to one facility. So if it just looks like you're in there, you know, a couple times a week because it's Tuesday, and this is just when I see my patients, that could be a problem for you under audit. There's our advanced care planning. So same process, counseling and discussion. So this absolutely, absolutely, we are dinging people all the time on advanced care planning because we're not documenting what we need to. So I encourage you to go back home and read through your LCD that talks about this. The counseling discussion and decisions needs to be documented. It's got to be documented. And we're not really doing such a bad job on that. Assess the patient's decision-making capacity before you go into your ACP discussions. Is that documented? A big one is requiring the permission. Okay. So a consent. The patient's actually supposed to consent to ACP before you start with it. And I think what this is coming from is that if you're in there and you're having this discussion with the patient, and all of a sudden you start down the road of ACP, and that's a separately billable procedure, how is that patient going to possibly know that or that surrogate decision-maker? How are they going to know that this is a separate, you know, service that you're providing and there might be cost sharing? So I think that that's really what's behind this. So if you're just saying, you know, I recommend that, you know, we do some advanced care planning. This is a separate service. Are you interested? I don't know how that conversation is going to take place. That's up to you and your patient. But you need to get that and then you need to put it in your notes, something along that line. We're not getting time. You got to have 16 minutes and we're not getting time. Every one of those you don't document your time and at least be 16 minutes, you need to refund them. I mean, technically you would need to refund those, okay? So that's going to be a hard stop. And if you're billing more than once, is there a change in the patient's condition that would really warrant the necessity of that? That would need to be clearly documented. So then again, that's your checklist for that. Things that we can trim down here a little bit on our E&M, hallelujah. We don't have to do the review of systems or past family medical and social histories. Exam doesn't contribute to our coding. So those of you in the office setting, you know this. Those of you that are not in the facility, just count your days down because January 1st, we don't have to worry about that anymore. So really Medicare has at least came on board and said, we got to get these docs from documenting stuff that's just really not necessary. Thank you. Thank you. Thank you. Thank you. So it's going to be so nice to have that go away. So get rid of your all others are negative, please. You know, we don't need to see that anymore. It's not going to make sense anymore, really. So unless you're really doing it still, the whole 14 system inventory, it doesn't make sense. But if, you know, those of you that are still in the facility setting, just hang on. You know, hang on until the end of the year. Now the one thing I do want to tell you is that on the history though, don't just, the history, guess what? The history is not part of coding anymore. I don't have to worry about it. You still need a medically appropriate history and exam. Okay. That's still written in CPT. But I want to tell you though that the history, you know, so either it's an HPI or an interval history, don't let go of that. Okay. Now you can kind of maybe focus on it just a little bit because you can get rid of the fluff. But that HPI or the interval history has so much influence on code selection. So me with my coder brain, I pick up your note and I start to read it and I'm like, oh, ooh, ah, you know, now the patient woke up this morning and, you know, and they're, you know, they have bloody stool or whatever. My brain immediately goes, ooh, this is going to be a higher, you know, more complex visit. So it really still has a lot of influence on there. So if I go to your assessment plan and I can't see that there's an exacerbation, you know, something along that line, I might be able to glean that information from the history. I'm still a big proponent of a well-written, doesn't have to be a book, but a well-written, succinct HPI or interval history so I understand what's going on, especially on those more severe cases. Issues identified. So we can go through, you know, this is not an E&M session. Okay. That's not what we're doing today. But this is how the new E&M guidelines are going to be written. So those of you that are in the facility setting do pay attention because you might be able to appreciate some of this. But on these low, like the low-level visits, we're looking at, see, here we go. Stable chronic illnesses. An acute uncomplicated illness. Okay. So that's where I'm saying I need to see it maybe in the history or the assessment plan because me, the coder, the auditor, the reader of your note needs to be able to categorize each of these conditions. So you need to make sure that the status is clear. The goals. Okay. So those of you that are doing some pain management and, you know, you're going to tell that patient in the beginning, you know, you're always going to have pain. We can't make your pain go away. Your goals are going to be to see if they, we can't make sure that you can get through your ADLs, remain independent, you know. So those are the conversations. So those are the goals. So the patient might have pain 5 of 10 today. I can't just assume that they're not at goal because that might be their goal. So you need to make sure that the goals are clearly stated within your note and especially like on those initial visits or those consultations so that we can understand if they're at goal or not at goal. And so for the purposes of coding now, the AMA came up with it and they basically said stable means at goal or approved. Unstable, not at goal. Okay. So if you hear me saying stable or unstable, they're kind of, you know, that's their little twist on that. So we need to know this. We need to know on an injury, is it complicated or uncomplicated? And those are actually written into the guidelines when you get really deep into them. So these are some of the problems that we have when we do reviews of these notes. I have these reviews. I work again, like I said, a lot with post-acute. And even though this is the new guidelines, I'm still struggling, you know, in the other world there because the chronic illnesses, you know, I don't know that there's a progression. I don't know it's a new complaint or an exacerbation. So I really need to know the status of those. And so you can kind of see how they start to graduate. You know, if you're looking at a moderately complex visit, you know, these are exacerbations, side effects. Those are those words that we're looking for here. Complicated injuries. You jump it up to high decision making, severe exacerbation. Okay. Make me feel it. So if you're doing that 99310 in a skilled facility, nursing facility, if you're in that office setting and you're wanting to click that button on that 99310 or that 99205 or 215, severe exacerbation. You tell me about it. Tell me why it's so horrible if you're not doing your time-based coding. Poses. Here's another thing for your risk. Poses a threat to life or bodily function. So me, the reader, picking up the note, make me frightened just by that history. Make me feel it. Make me feel it. So those are some of those things that we're looking for here. Your data. I talked about this earlier. Whether you're under the old guidelines or the new guidelines, tell me what you're reviewing. Don't just say lab review or images reviewed. I don't know what you're talking about. Under the new guidelines, you get to start collecting for each unique test. Okay. So whether it's radiology or whether it's laboratory, for each unique, I start to collect all of those. It used to be just no matter how many tests you reviewed, dill cows came home, you got one point. But now they're actually recognizing those unique tests. So tell me what they were so I can give you credit. Independent historians really starts to carry a lot of weight. So if you're having to go out and get that history from someone other than the patient, tell me that that's where that's coming from because it starts to come into this whole data collection. And that's the old way and plus the new way too. Your independent interpretation of test, I told you about that already. So as long as you're not billing for that, but you're looking at the image and that's your interpretation, make sure that I understand that so you get the appropriate data points for that. And then this just kind of graduates. So all the data points kind of stay the same for each level. It's just that you need more data points to be moderate and then you need a lot of data points to be in that high category. So you're thinking that if you had a radiologist report and yet they don't make a comment about it, but then you do when you look at it? For example, when you look at MRI of the back, they don't mention there was a heart attack. Oh, okay, yeah. So that MRI and you see something they didn't comment about. It doesn't, the only thing it would do is say whether you found something or you didn't or you agreed, you just comment about it and you're gonna get those data points for that personal interpretation. Okay. So then we said, then we move on to the risk. They've rewrote it just a little bit. And so really it's more about your management options. Okay. So your management options, what are you doing to manage this patient that would create risk specific to that patient? Prescription drug management. Everybody loves that whole, it's a four. I did prescription drug management. I wrote a prescription. It's a level four. I've been hearing that for years. I've been hearing it from pediatricians on a healthy five-year-old with otitis and they're writing a prescription for amoxicillin. And I was like, really? Really? And yet my pain management people dealing with narcotics, it's not the same thing. It's not the same thing. So we still have to be a little bit careful about that. But prescription drug management, and why I have this little arrow up here and says it has to be an action. So if you just give me a diagnosis and tell me what they're on, it's really not management. Now, if you want them to continue it, you're managing it. You're gonna start it, increase it, decrease it, discontinue it, continue it. That's an action. But just giving me a diagnosis with nothing but the prescription, that's not really management. So think about the way you're writing that and your language that you're using. Yes, sir. Well, he's asking, well, what if I wanted to start them on a drug, but yet then I go back and I'm thinking with contraindications, or the patient says, oh, no, no, no, no, I'm not going to do that, you'll still get credit for it, okay, especially under the new guidelines. So whether you moved forward with the procedure, diagnostic, or the treatment that you're recommending, and then you're going back and going, no, I don't really think we should be doing this, you can still get credit for that, okay, because you're still, you're going through the work of that. Going through the work of that. I'm going to take one more question, then we'll go on to our next slide, just to kind of stay on track. I'm sorry. So you're doing the rounds with who? You're doing it so you're doing the whole substant thing and you're trying to bill under your bill under your number for that higher reimbursement Well, you're asking if you can build a split shirt really so that's what you want to look at is the split shared billing provision Which means you're working in conjunction with that PA or the nurse practitioner doing your rounds and so that There it's so complicated It's not and it is it's it's bigger than just in this session right now But you would have to go in and document what your substantive portion of that visit was And so did you do all the history all the exam all the decision-making so if there's multiple layers to that but I would encourage you to go home and just Google search Medicare split shared and read about it because Yeah, yeah, you could still, yeah, you can always go the conservative route and bill on your nurse practitioner, right, right, you can always do that. So we had our must, that was a big thing that I wanted to point out to you, document your patient or, you know, procedure risk specific to that patient. And then high risk, you know, look at what your examples are. These are so easy to find. You can just Google search, you know, 2023 E&M changes or the 2021 and you're going to get them there. So I just wanted to give you the examples of what that looked like. So other things I wanted to bring up real quick, templates, please be, I have a love and hate relationship with the templates. We even use them in our own office and I get on to my audit team about that, I'm like, now you're guilty of what you're, you know, you're sitting there accusing your physicians of doing. So the templates really should be like an introduction to a topic, okay, then you fill in the patient specific information on that, whether it's a little blank in the middle of that template or at the end, but it's really more of an, it's a prompt. It's a prompt for patient specific information. So the minute you create some kind of a template and you just sit there and you pop it on to each one of them, boom, boom, boom, boom, then Medicare, your payer comes in and looks at a series of visits and every one of them are the same, it's going to be a problem. Same thing about time-based coding, anything that's time-based. We pull that, by golly, every single note, like on your ACP, that advanced care planning, every single one of them, you spent 16 minutes, every one of them, or more than 16, or more than 30, you know, so don't do that. Be a little bit more precise, okay, be precise in that. Same thing with copy and paste, you know, be careful with your copy and paste because I will pull up a note, I'll pull up a note and I'm like, oh, look at everything they did this day, why did they code it so low? I mean, gosh, they're, you know, they're reviewing diagnostics and they're prescribing something and I'm like, gosh, this is a complicated visit and you build it as a low and then something doesn't quite make sense and I go look at the visit before and I'm like, mm-hmm, because you did it the, oh, no, no, oh, no, oh, this has been going on for two years, okay. So you have to be careful because immediately you might find yourself with Medicare or payer saying you undercoded because you did all this work, well, no, you didn't. So, you know, label it, if you want to bring it forward, label it, do something, but don't let it just sit there and bring forward to make it look like everything that you're doing, okay, because you didn't start that medication for every visit over the last six visits. So really do be careful with that, bringing forward that information. Talked about that time, time base there, making sure that you really are specific to the case, document, you know, how your time was spent, that's really important to get that in there, counseling, interacting with a care plan, you know, phone calls, discussing information, going over treatment options, forms, and that's what I said, so what it's going to say for every single patient, it really starts to lose credibility when they look at that. And just some other things here too, you can read these back on your own, orders differing from the procedure, title of the procedure describes it differently than what's in the body of the note, well, from a coder, what am I supposed to use, the title up here, or am I supposed to use the body, a coder's always going to tell you to use what's in the body of the note, not the header, okay, so however you just do your little summary up here, a coder's taught, we only code from the body of the note, so the body of the note typically is going to trump what you labeled it across the top. Making sure the meds are in there, pain levels, inconsistency, we'll see this sometimes, and a lot of times it's just your patients are unreliable, right, they're just unreliable, so we go look, and at one point, right immediately after the procedure, they're like, oh, it's 90%, then you ask them a few days later when you do a follow-up phone call, now again, what was your pain level right after it, oh, it was 80, then they come in the office, now what was your pain right after that procedure, oh, it was a 60, you know, 60%, so even your patients are inconsistent, but it can be a problem under audit, so just something for you to be aware of. Indications for the procedures, exactly the same for every patient, so you've got this lovely little template, and again, it's going to be difficult for that to fly. So the summary is just, you know, routine reviews of your coding and documentation, and you get that independent review, and that could even be somebody within your organization, so you have an audit program within your large system or medium or small system, whatever it may be, but you get that coder to come in and kind of pick it apart and let you know. We talked about following up on those areas, emphasize the importance of the records release process, okay, so if you're under appeal or audit of some sort, don't overlook the importance of that. Categorize conditions, we talked about that importance of that acute and chronic, detail of the data, case specifics, caution with the templates and the copying the information forward. Okay, so we have just about, I'm sorry, about five or six minutes, but we've taken questions along the way, so I'm going to open that back up here for just a couple of minutes, and so if you have anything to add, Dr. Gerson, anything in particular, and then we can go back and... No, that was great. The only thing I would say is your Reimbursement and Policy Review Committee is always happy to hear from our members if people have specific billing and coding questions along the way. You can find the contact information on our website or email healthpolicy at aapmnr.org with any questions. Okay, that's great, great to know. So then, I'm going to go back to this gentleman, because you did have your hand up earlier. Okay. So, I think I understand your question. So, you're in a facility setting when you're seeing these patients, maybe even on a daily basis. And he said, well, but I'm making sure that those complications aren't taking place, like the Lovenox. And so, really, it's monitoring, evaluating, assessing, or treating, right? So, are you doing a physical exam, maybe? You know, so there you go. So, I want to know that you really are assessing it. Simply by putting a problem list down there with nothing that's really telling me that you're updating it, evaluating it, examining it, managing it, then that's where we come back in and say, I can't give you credit for that. You know, so the fact that you're doing that exam and the fact that the patient, you know, is showing no signs of, I'm going to give you credit for that. So, that's what I'm looking for, that you really did evaluate it. A lot of times, we seriously do see them bringing the problem list in, dropping it down there, and really nothing, I can't get anything in the history, I can't get anything in an exam, I can't get anything, you know, I'm like, I don't, I can't tell that you really did evaluate it. And I'm not saying you didn't, but, you know, the whole adage, you know, if you didn't document it, then you didn't do it, which I absolutely hate that term. To me, at least for in my world, it's like, you didn't document it, it's not codable. And I'd rather look at it that way. Let's go with another question here. Oh, we got several, so. Oh, oh, denying the whole stay. Denying the whole stay, so we appeal them. Yeah. So is there any... No, there's not, I don't think there's any downside to appealing. When you feel like you've been wronged, you need to appeal it. Absolutely, absolutely. Yeah, it's hard to tell it seriously. It's hard to tell how that the whole selection process is and especially if you start to Talk about denying an entire stay. I don't live in the facility world, you know So if it's anything to do on that side, that's kind of outside of my area of expertise I'm just kind of over here in the physician side of things It's where I've always lived and where I always always will be I had an opportunity to work for a payer a few years ago in their investigation unit I was really intrigued by that and I thought well Wouldn't that make me really good if I went work for them a couple years and then I went back to the other side And I just can't do it. I just I I just really still like this whole education piece and and really helping you all out right right so if you're Yeah, and if you're in that facility setting or a larger institution, like you said, somebody needs to be in charge, and it depends on what all's going on, and it might be a full-time job, but somebody needs to be in charge of responding to these records requests. And I think a lot of times people are just like, oh, it's a records clerk. No, no it's not. No, it's not. So if you're gonna lose all that money on a stay because you're not doing something correctly, then you're gonna get that investment back on having somebody in charge of that. It needs to be a really well-thought-out process. It really does. And so the way you would handle that on the facility side would be a little bit different than we would on the physician side. And hopefully on the physician side, we wouldn't have hopefully the need for a full-time person, but I know that like on the facility side, they have people that do nothing but work with the RAC requests. So the recovery audit contractor requests. We have time for one more question. Right. Right. Right. Yeah. So you said ordered it or, you know, for decreasing, increasing. So any kind of change at all, but the ordering, even the discontinuation of those, those are just kind of like your buzzwords. And whether, and again, even those of you that are still on the 95, 97, I still need to know that. I still need to know that for that prescription drug management. So you, like I said, the failure, but the whole goals, acute, complicated, the severe, you know, so all of that terminology. And, and I think that one of the best things that you can maybe do for yourself, like I said, go out and just kind of Google search 2020, 2021 E and M changes. You should be able to get a document to come up from the AMA and it has this lovely little table and it'll show you how all of that is categorized and you can kind of see, okay, I see where this is going and you can kind of go back and incorporate that into your notes a little bit. And it, and if you have problems with that, just, just email me. My, my card's up there too, if you need my contact information and just let me, and I'll, I'll just send it to you and say, here you go. And this is what we were talking about. And we also have resources on our website about the new E and M coding changes and the new ones coming down the road for SNFs. So, okay. Well, I think we're going to end our session, but my flight was delayed. So I have time to stick around if you just want to come ask me questions. Thank you all so much for coming. Thank you, Linda.

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