Thanks for joining. We're going to wait until the top of the hour to get the session started. Hello, everyone. My name is Carolyn Millett. I'm the Director of Reimbursement and Regulatory Affairs with the Academy. I'm excited to welcome you to our session tonight. We're going to be learning about evaluation management coding changes for 2023 in the inpatient rehabilitation and nursing facility settings. Next slide. Oops. Sorry, they're changing on this one but they're not changing on. There we go. I apologize. All right. Um, so just a couple of housekeeping things before we get started. We are recording this session and it will be made available on the Academy's online learning portal. We've muted all microphones and during Q&A, we can unmute you, though we will likely try to just answer questions through the chat or the Q&A feature. And we may not get to every question but we are going to do our best to respond to questions in writing if we don't get to them during this session. Next slide. There are a couple of options for submitting questions. You can submit questions through the chat or you can submit questions through the Q&A feature. So those should be available to you at the bottom of your screen. All right, so I'm going to turn this over to Dr. Lauren Shapiro. Dr. Shapiro is chair of our inpatient rehabilitation member community, as well as being a member of the Academy's Reimbursement and Policy Review Committee. Dr. Shapiro is going to introduce our speaker, and then she will moderate the Q&A at the end. Thanks so much, Dr. Shapiro. Thank you, Carolyn, for all of your work coordinating tonight's event. I'd like to welcome all the members of the inpatient rehab member community joining us, as well as those joining us from the inpatient consultants and skilled nursing facility groups. I'm very excited to learn more about this topic this evening and to introduce our speaker. Linda Duckworth has over 30 years 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 government payers. She has assisted clients with meeting their corporate integrity agreement obligations, worked through their diversion agreements, helped those who have been accused of wasteful billing practices, and she's been involved with defense teams in healthcare fraud investigations and false claims accusations. She has 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. I will now turn things over to her and thank her for being here this evening. Thank you, Dr. Shapiro. I appreciate that, and I appreciate everybody joining us this evening to get through the new changes in 2023 that we're all dealing with out there. Just a quick disclaimer here as far as this presentation is not meant to replace CPT, a manual at all, and all of the guidelines that go with it. My personal disclaimer to all of you is that I really encourage you to go out and read the full set of guidelines, especially those areas that pertain to your area of specialty. I gave you the link right here to the AMA document. I think it's about 42 pages, but not all of that is going to apply to you, but you can get the full definitions of the topics we're going to talk about tonight and maybe a little bit more detailed instruction. This is only meant to be an overview. We have a short amount of time to get through a lot of information. I'm really going to try to hit the high points of this, emphasize those things that you need to know and your takeaways for tonight. I'm hoping that you get some good documentation tips and code selection tips so that you can walk away from this and start implementing them right away. In 2023, what happened with AMA revising our codes, our evaluation and management, we now have two ways to get to our code selection. We can either go by the medical decision making, and it's been restructured, or we can actually do time-based coding, and it's been redefined, and I'm really happy about that. I have information about how we go about selecting that as well. Now, the AMA said that their goal in rewriting these instructions were to decrease administrative burden of documentation and coding and align CPT and CMS whenever possible. They've done a really good job, but we still have some gaps out there that we need to talk about, and they want to decrease unnecessary documentation in the medical record that's not needed for patient care. Again, that's another win for the providers out there. When we talk about decreasing, I'm so excited about this. We can get rid of some of that fluff. When we're talking about the past medical, family, and social histories, we can do away with all of that superfluous documentation. We're looking for the medically appropriate history and exam, and that's up to the provider. If you want to do a complete review of systems, that's fine, or you want to gather all the past family, medical, and social histories, that's fine. It's up to you. Totally your call, but only a medically appropriate history and exam. Now, Medicare has gone in, and on a lot of the education that our company has sat in on, they're saying that they must have a history or exam, and that if one of those is not necessary, you should probably document the reason why. So that's what they're saying out there, but that's kind of a Medicare thing that they're saying in their education. Now, the other thing I want to talk about real quick, though, is that the history still has a considerable amount of influence on code selection. So a lot of times, I pick up the note, and I start reading the history, the HPI, and I have a really good idea probably where this visit's going to land by the time I get down to the end of the note. Now, maybe something in the assessment plan is going to change my mind, absolutely, but I get a good feel just by reading that history. So it sets the tone for the visit, and coders kind of rely on that, or reviewers will rely on that, the person reading your note. So it talks about the severity sometimes, or the chronicity, maybe associated signs and symptoms that kind of help us understand maybe there's a differential out there. And then also, we need to know the status, and so we can pick up that on the history as well. So don't overlook the importance of a well-written HPI. So there's three components to the decision-making process. We're going to look at the problems addressed, the data, and then we'll look at the risks with your management decisions made during that encounter. Now, the problems addressed, when we talk about that, we're talking about those that were evaluated or treated during this encounter. And it also includes those conditions where maybe further testing or treatment's not necessarily going to take place today, and that might be because of a risk-to-benefit analysis by either yourself, maybe the patient or the family declines, that they don't want to further evaluate the reason behind maybe dad has been coughing up blood lately, and he's got a long history of smoking, and they're just like, you know, at this point, we just don't want to look that up, whatever that may be. So even if you're evaluating this, and even though you don't move forward with an investigative process or with treating it, it still counts as a problem addressed. Now, we want to limit the problems addressed to the current encounter, and sometimes that can even differ greatly from the reason that the patient was admitted. So if you're following up with that patient maybe a week later, and you're asked to go in and see them for a skin tear, then what are we going to do today? We're going to account the skin tear towards our problems addressed. And then certainly if any other issues, chronic or whatever that may be, are brought up, that's fine, but as long as we can really see that they were managed or addressed or treated or evaluated today, that's so important for our code selection. The AMA goes a little bit further into this, and again, I'm pulling most of this straight from the AMA guidelines, and CMS has actually adopted the AMA guidelines, so it's very important that we're familiar with these. The other thing that I want you, I need you to do, so me, the coder or a reviewer, what I need you to do is tell me if a condition is acute or if it's chronic, and what I mean for those that are less than obvious. So if a patient is having back pain, I don't know if that's an acute problem. Is it just started in the last couple of weeks, or is this a chronic problem? And I need the status of those conditions, especially those that are chronic. So those that are not stable are weighted more than those that are. And so what that means, if that patient's not at goal or if that chronic condition is worsening, you want to get yourself in the habit of using language that would convey that to the reader because they're weighted more. So a patient that has hypertension and we're having problems with that blood pressure, and the blood pressures keep going up even though we've adjusted their medications, that type of a presenting problem would align with a moderate type of visit versus a blood pressure that you've got good control, and we would call that stable, and we'll talk about the word stable here in another moment or two, but that would be stable, well-controlled, and that would align more with a low type of visit. So chronic or acute, let me know those that are less obvious. And then if it's chronic, please let me know the status. Is it stable or improving, or if it's worsening, under control, those kinds of words. Now, comorbidities and underlying diseases are not really used in that decision-making calculation unless they're really addressed today. So did you address and did they directly impact the amount of data or your treatment options? And if they did, then we would want to see them documented in that note so I can pick up on that as a coder or as a reviewer. Now, symptoms or the final diagnosis can be used as a problem addressed, and so the AMA says if an extensive evaluation occurred and only to find out that it's maybe not a patient's not having a stroke, patient's not having a heart attack, but all of the work that took place leading up to that to figure out that's what they're doing, and we're doing stroke protocol, chest pain protocol, whatever that may be in that kind of a situation, even though it turns out being indigestion, what is my presenting problem? Well, based on all of the work and the way it presented and the patient's history and the way that my provider documented it, it's leading us to believe that they felt like this very serious acute event had to be ruled out. So even though my diagnosis might not be there, but the presenting problem, though, was. So you'll just want to make sure, again, you're conveying that within your note. So now the AMA is using the word stable, which might be a little different than how you would typically use it in your clinical scenario here. So what they're saying is if it's stable, it's at that patient-specific treatment goal. When it's not a goal, the condition is not stable, even if no change and there's no short-term threat to life or function. So specific treatment goals. We might be happy with some of the population of patients that you all are taking care of. If their blood pressures are under 160, you're going to be pleased. Maybe the blood pressures are under 130 and you're going to be pleased with that. Maybe it's a pain goal that's specific. We can never get the patient's pain to go completely away. What's my patient's goal? Keep it around a three to where they can get through their ADLs comfortably. So it's really about the patient goal. So it's important that you express the patient's goal. And are they meeting those goals? Are they improving? Or if not, again, choose some words that let the reader know that they're not a goal or possibly these conditions might be worsening. We've got an acute uncomplicated illness or injury. And AMA defines that as full recovery without functional impairment is expected. So if you have some kind of an acute illness or an injury, you might want to be thinking about the way that you're describing that. Is this an uncomplicated or a complicated situation? And again, it's going to make a difference in our code calculation. And I'm going to show this to you on a table here in just a moment. I'm not going to read through every one of these. You will get a copy of this PowerPoint. And AAPMNR is going to make it available to you all that you can go back and read each one of these items. We just don't have time to do it except for the purposes and the time constraints that we have this evening. So a stable acute illness, that is a problem that is new or recent where treatment's been initiated. Maybe you're seeing that patient in a follow-up situation in an acute setting especially. The patient is improved. So it's going to be stable if it's improved. While maybe resolution is not there yet, we can still call it stable. Chronic illness with exacerbation, progression, side effects. So chronic illness is acutely worsening, poorly controlled, or progressing. You want to describe it that way because, again, remember that is going to be weighted more than those that are stable. An undiagnosed new problem with an uncertain prognosis. In the differential diagnosis, it's going to represent a condition likely to result in a high-risk morbidity. So you would want to use that language and let us know that. An acute illness with systemic symptoms. Illness causing systemic symptoms might be looking at a pneumonitis, colitis, those kinds of presenting problems. And those are actually going to fall in the moderate category unless you use words to tell me that these are more of a severe situation. And I'll show you that here in just a moment. You've got an acute complicated injury. So if that patient falls out of bed, falls while they're in physical therapy, whatever that may be. We're talking about complicated. It's an evaluation of a body system or evaluation of body systems that are not directly part of the injured organ. Or the injury is extensive. Or the treatment options are going to be multiple or associated with risk of morbidity. So, again, when they have an injury, they have the fall, they've got their hip pain. Then let us know the degree of that so that we can place it in the right category and weight it the way that it should. So here's problems addressed. Now, both of these are high complexity. And this applies to whether you're in the nursing facility or in the inpatient rehab facility, okay? All of this applies to both settings. And I'm going to tell you one, there's one exception, and you're going to know it here in just a moment. So this is what we're talking about when we're talking about high complexity, high decision making, getting you to that 99223, the 233, the 306, or the 310. So we were looking for chronic illnesses with severe exacerbation, progression, or side effects. The severe exacerbation or progression of that chronic illness, severe side effects, significant risk of morbidity. So that patient is having a severe exacerbation of that COPD. You need to use those kinds of words, get them in there to make that reader understand that that's the degree of severity on that. You've got an acute or chronic illness or injury that poses threat to life or bodily function. Looking for that language, again, poses a threat to life or bodily function in the near term without treatment. Some symptoms significantly probable that, and then this is kind of what I was saying earlier on that presenting problem. So some symptoms that might significantly be probable, a potential threat or life to bodily function, but it turns out that they're not. They just have indigestion and not having a heart attack. This is, again, one of those that's going to be consistent with this type of presenting problem. So consistent with the degree of potential severity. So just, again, let us know that's what's going through your mind when you're doing your documentation. So this is unique to the initial skilled nursing facility visits. And at the bottom, you can see where Ventra says that we believe that's reserved for initial comprehensive evaluations only. And I believe we have confirmation coming back from CMS now saying that would be correct. It would only be on the comprehensive visit that would be done by a physician. So it's a set of condition syndromes or functional impairments that are likely to require frequent medication changes or other treatment changes and or re-evaluations. Patients at significant risk of worsening medical, including behavioral, status and risk for readmission to the hospital. Boom. This applies so much to so many of your patients. And now you've really got a great presenting problem that is recognized, right? Now, the downside to this, though, is we're still going to have to have some data or some risk with the management options to get us to that high level of code. And I'll show you that here in a moment. So documentation tip is going to be document your patient specifics. Don't just go and copy this and just start putting it in as like a short phrase or a macro into your as a template into your notes and, you know, and just using and relying on it all the time. I don't recommend that we do that. We would want to make sure that we have patient specifics and maybe some type of, you know, the information is actually built into maybe that evenly assessment plan that's going to get us there. So now let's move on to our data. So we talked about probable problems addressed one component of decision making. Now we're going to look at that data, the data. There's a lot to it here, a lot of different options. So, again, this is really one of those areas. Maybe you do need to go read either all of these slides or go read the guidelines, because you'll be able to fully understand everything that you do that would count and apply towards the data. So when we talk about what's being analyzed providers within the same group. So if we're talking about lab or imaging physiologic data providers within the same group will count the order or the review, but not both. You can't do both. You get the order or the review. Pick one. You don't get both. Probably best to just adopt a policy that we only count the orders and not the review. And even if that order or review takes place on another day, or even if it's by another provider within your group, because your payers and especially Medicare sees all of you within the same specialty within the same group when it comes to billing. It's like as if you are one. So as long as your providers are all in the same group, you only get to do the order, or you get to do the review, even if it's two days later and someone else has seen the patient and follow up, you only get to do the order. You don't want to credit data points for separately billable services. For an example, if by chance you are looking at the EKG, and you're generating your own personal interpretation and report of that. And you're going to bill for that through a CPT code, you cannot use the data points for personal interpretation and apply them to your evaluation and management code. So that's a big rule, we have to be careful about that. A unique test is defined by CPT codes. So think about your CMP, your lab. So there's multiple results in there, but it's reported by one CPT code. And so a CMP would be one test, CBC, one test. So anything with multiple results, but gets reported back through one CPT code is going to count as one test. And I know you as providers sometimes you're over there shaking your head, well, how am I supposed to know exactly what gets reported, you know, per CPT and I understand that's a real challenge. And I have to tell you, I'm not really sure I have a lot of answers for you. But this is how the rules have been written. Now when we talk about a unique source for information or discussions, if you're getting information from the unique source, or for a discussion or information, that source needs to be a distinct group, or a provider of a different specialty within your group, or a unique entity. And what that means is the physician reviews his or her partner's HMP from two days ago, and maybe it took a few minutes to review it. But because you're within the same specialty, and you're within the same group, the provider doing the second visit won't be able to use that towards their data points. So what we would be looking for is maybe a review of like the acute stay leading up to this this day, or maybe ER notes, you sent them out, they came back, you know, especially that happens a lot when we're talking about the post acute, Maybe notes from the cardiologist, that's a different specialty, probably a different group than where you're practicing. So that's what we're talking about. Review from all materials from a unique source counts as one item. Now what that means is maybe you're going in and you're reviewing the hospital notes from that acute stay and you've got test results and you've got, well usually test results are embedded in there, maybe comments from other providers, but as long as you're getting that from all just one source, just the inpatient notes, everything in there is kind of bundled up in there and you just get one data point for that. I'll show you again here in a moment a little bit better illustration of that. The other thing I want to talk about is discussion. So when you're having discussions, it's so important that you document that because you're going to get credit for this. So all of this speaks to this additional work that is required and you need to know what counts, what qualifies, what we need to see documented, and then that way you can get credit for it. So those discussions, we're talking about an interactive exchange. So the exchange has to be through, cannot be through an intermediary, you know, sending chart notes, written exchanges within progress notes does not qualify as an interactive exchange. So those telephone calls or maybe using some type of a platform that allows you to do some live interaction, those kinds of things, document them, and then you'll get credit for it. Independent historians, that comes up a lot for both of these settings. And so when you have that family member or it could be, you know, a caregiver, someone who significantly contributes to that history, you get credit for in involving that independent historian. And so you want to make that clear. According to the wife, lately, the patient has been complaining of, and then go into some detail about this. And so they're going to provide the history, they're going to supplement the history. And then also, it does not include your translation services. So be careful in that. And it does not have to be done in person. So it would include telephone calls with that other person. So if you need to make those phone calls and talk to them, to a family member to get that full history on that patient, let us know that that's what took place, you're going to get a data point for that. If you're doing that into independent interpretation, remember, like the EKG, you want to make sure that that their reader knows. So if you're not billing it, you're not billing for it, but you're going to look at that EKG, or you're going to look at a chest x-ray image, you let us know that you're personally interpreting that image or that tracing, because that's weighted more than if you simply read a cardiologist interpret the EKG or a radiologist interp of that of that chest x-ray. So your personal interpretation is going to count more for that. An appropriate source. So when we were talking about discussion of management options, I just want you to know that there's other options. It doesn't necessarily have to be a health care provider, it could even include a case manager. Risk. When we're talking about risk, this is with your management decisions being made during this encounter, your management decisions. So not necessarily the presenting problem. So we're already giving credit to the presenting problem and that acuity of that presenting problem, your problems addressed, right? So that's kind of where that's coming from. So now we want to come over here and look, but what kind of risks are your management options going to pose to that patient? Risk is based upon consequences of the problems addressed when appropriately treated. Risk also includes diagnostics or management options when they're not carried out. So kind of like the presenting problem when we said the patient's coughing up blood and we should probably investigate that. So we get to count that as a problem addressed, but we're going to come over here also and any type of recommendations you would make for treatment, maybe it's something that you're thinking that you need to start an antibiotic on and the patient refuses to do that, you would still get credit in the risk column because you went to the work of saying this is what needs to be done, but the patient refuses, or because of something else going on, you're not going to be able to do that, okay? So even if it doesn't end up happening, the fact that you considered it, still going to get credit. So document that work. Document your reasons why you can't do something or why you're not going to do something. Social determinants also come into play. So when they're part of your medical decision making during this visit, you would document it. So when you're going to have those challenges, when that patient is being discharged and there's going to be issues with them getting the medications they need, transportation to their doctor's appointments, whatever that may be, and it's adding to the complexity of your visit, you can document the social determinants of health and it'll fall into that moderate category. So it's an option for us in the risk table. I'm not going to go over the surgeries, and again, you can read those later if you want to. Drug therapy requiring intensive monitoring. I'm not going to go into a lot of detail about this. The thing that comes to mind for me with this group of providers that we're speaking to tonight is possibly some of those really nasty antibiotics that you're managing or you're helping to monitor. Those might come into play in this type of a drug. I mean, not being a clinician, it's difficult for me to come up with any other good examples, but you can read about this on the AMA website or you can read through it a little bit more later on this slide if you need to. So calculating the code. Again, we said we've got our problems addressed, got our data, and then we've got our risk, and when we're coming up with our code, we only need to meet two of those, and I'm going to show you a couple of different times how that comes together. Now straightforward visit. I know that sometimes you're thinking when would this really ever happen, but once in a while they do crop up and this is the way the guidelines are written, so I think that we have to include them in our presentation this evening. So the straightforward, your problems addressed would be self-limited or minor, minimal or risk of morbidity or from diagnostic testing or treatment, so there really wouldn't be anything there, and then also risk of morbidity from diagnostic testing or treatment. Oh, I'm sorry. It looks like we've got a duplication there. I apologize. The data should, that's why I was reading it sounded a little off. The data should be minimal or should be none, so I definitely need to get that corrected. I apologize for that, and so that's what we, that's the type of visit we would be dealing with on those low, those lower ends, and so I could definitely see maybe in the nursing facility environment this will, this will come up once in a while, and this is something that we would be coding more than likely a 99307 in that setting there. So calculating the code, a low visit, so now we're going to go up a level and we're going to have low, so let's just say we've got a patient complaining of rash, arms and legs, it's contact dermatitis, family got her some new lotion, and the nursing is going to monitor it, and then we're going to go with an over-the-counter, you know, hydrocortisone cream, and then also, by the way, blood pressures have been well controlled since the last visit, so what I have to do, this is how your coders are going to abstract this, this is how a reviewer would it appear, so they're going to take each of your problems that were addressed, and they're going to put them into a category, so we're going to say that we've got acute uncomplicated illness or injury on that rash, I don't know, maybe you could even say it was a self-limited or minor, you could maybe argue that back that way too. For me, I'm thinking if my, if my provider is going to give them either an over-the-counter or a prescription, I'm probably going to bump that up and keep it to that acute uncomplicated, and then you've got a stable chronic illness on that blood pressure, and then we don't have any data, and then we're not doing any prescription drug management or anything else that would give us a moderate type risk, so just based on the two of the three there, I would have a low-level visit, regardless of the setting, this would be the still the acute rehab or in that nursing facility setting, either way it's going to code the same. Now jumping up to moderate, so what are some of our options when we look at the moderate, what comes into play, so you've got a chronic illness with an exacerbation, one of those would take you to moderate, what if you have two or more stable chronic illnesses, that alone puts you into the moderate category, you could have an acute illness with systemic symptoms, or you can have an acute complicated injury, one of those would put you in the moderate category. Then we look at our data, what do I need for the data, now I've got category one, two, and three, and I only need to meet one of those to get moderate type data, so I would have to have any combination of three of the following, so maybe I'm going to deal with some lab tests, maybe I'm going to get the independent historian, the wife to chime in on the history, and two labs, two x-rays, I'm going to have that moderate data, or I could do an independent interpretation of a test, that's all I would need, or I could do have discussion of management or tests with another provider, that alone would make it moderate data. Then I jump over to the risks, and of course we have prescription drug management, we're going to be using that all the time, all the time, and then the other one I wanted to point out, like I said earlier, your social determinants would fall into the moderate risk as long as you document them well, and I can see that they really do affect the complexity of that decision-making process. Now here's your high, okay, so the highs are going to be those, the 223 on your admissions, your 233 sub days, 306 initial in the nursing, or the 310s, right, so we're going to look for severe exacerbation, or an acute illness or injury poses life to bodily function, multiple morbidities on that initial nursing, so those are some of my options. Then my extensive data, I would need extensive data, two of the three, so is it going to be the independent historian and the lab or the x-rays, or is it going to be interpreting tests, or discussion of management, I would need two of the three of those to be extensive, and then I look what are my management options, so drug therapy on that intensive monitoring, decision regarding hospitalization or escalation of hospital care, we're going to talk about that here in a moment because there's a cautionary note that goes with that, but again, I would only need two of the three columns there to get to that high code, to get to that higher code, problems addressed, risk, or is it going to be problems addressed and data, you know, so how is that going to play out, and we're going to demonstrate this again here in just another moment. So let's talk about prescription drug management real quick, okay, so we can't just have a list of meds the patient's on and maybe sitting there next to the diagnosis because it's just a medication list, so if you just give me the med they're on, it's a medication list, so what we're looking for is that you, the provider, we're evaluating the appropriateness of that medication, maybe you're continuing to prescribe that medication because it is compensating the COPD because the patient does have well-controlled hypertension, so you're going to continue that medication, so it's almost like you have to have an action, okay, think about that, for the prescription drug management, it's like you have to have an action, are you going to start it, stop it, increase it, are you going to hold it or continue it, so there has to be an action or it's really not going to account for this prescription drug management, so evaluate the appropriateness, continue it, maybe it's going to be drugs that are being considered and the reason why, maybe it's going to be a decision to discontinue on a medication or adjust it, maybe you need to discuss a patient's condition, possible adverse effects, potential benefits, so there's these, you know, these discussions taking place about these prescriptions, so those are the kinds of things that we're looking for, sometimes we'll see a note and it'll just say, and I had that a couple of slides ago, where the patient had the rash and then it said the patient's blood pressure was controlled in an on-licinopril, well, they're on-licinopril, well, you know, so do we, what's our action, are we going to continue with that, so that's where we want to make sure that we're conveying, you know, what you're doing, now, maybe that's in your orders, maybe you could go to nursing orders and we would be able to see some of this taking place, but the problem is that if you're going to submit your notes to a payer, more than likely, somebody's not going to know to go print that off to supplement your progress notes, so it's best that you go ahead and include it in the progress note. Provider has evaluated medications during the E&M as it relates to the patient's current condition, simply listing the med that the patient takes is not prescription drug management, so that's coming from your payer there. Here's some more for Medicare, this is not prescription, this is going back to the presenting problem, high risk option for the previous table, when we're talking about the decision regarding hospitalization or escalation of hospital care, remember that was an option in our risk column, so you're thinking this patient's got altered mental status, they could be having a stroke, so I need to send them over to the hospital, and so you're thinking there you go, I'm going to be escalating my care, or I'm going to make the decision for hospitalization, that's where that's going to light, right? Well, this is kind of what you would think, this is maybe a hard pill for us to swallow, but this is coming from Medicare, from multiple Medicare administrative contractors, okay, and what they're saying is, I'm going to back up for just a moment, on the decision regarding hospitalization or escalation of care, according to the AMA and the guidelines, page 7, you can only use that for hospitalized or observation care patients, okay, those of us in the nursing facility, SNFs, we can't use that as an option, okay, it doesn't apply in that setting, Medicare is saying for the decision on hospitalization, so the question has came through, for the decision regarding hospitalization, can it be used if sending the patient to the ER to evaluate and basically, they're saying no, so according to Medicare, the documentation is going to show your decision making, they're going to look at the documentation to determine if the practitioner is sending the patient for evaluation by the ER physician or sending the patient to the ER to accomplish the admission, so I want you to be aware of that, it just sounds like to me, when you look at the tables, that seems like a perfect example of what we would, you know, what we would select for those types of patients, only you can see where Medicare is saying, no, we're not going to, we're not going to recognize that in this setting, so I want you to be aware of that, so here's some documentation challenges, in the patient notes, green font is the notes, I'm actually doing this with a group I work with right now, I'm going through and taking their notes and we're finding this to be an excellent way to educate and give them feedback better than almost like a traditional audit report, I think personally, my audit reports are glorious and I think that they're very educational and as wonderful as I might think that they are, we're finding that they really give this great benefit by us going in, our team going in and adding in like green font, you know, saying that that's a really good job of explaining this or hey, this could have been better, so that's what we're doing, so this is one of those visits and here where I was telling you, if you're going to do review of the prior external notes, let me know that that's what you're doing, that this is a, you know, a recap of the of the notes, so you'll want to start maybe out by saying according to the hospital notes and then I'm, okay, I know exactly where this information come for, came from and I'm going to give you that that data credit for it and if you take that hospital summary, that history, like you see kind of here in this area right here and you bring it forward in your subsequent notes, can't count that again, okay, and your partner can't count it again in a subsequent visit either and then you can't pull out the test results, I was trying to kind of explain that earlier, so in this summary, I'm going to have a review of external notes only, I don't get to say, oh, well, I have review of external notes and I have a CT and I have a UA and I have a chest x-ray, so all of this gets bundled up into one. Now, this is a nice recap of that history of that previous day, but my note back to my provider was, but how's the patient during this visit, we kind of skipped that part of it, so I don't really know how they were during this encounter, so it would be nice if they, if they gave a nice update on that. The previous slide, that patient was admitted on February 4th and then they were put into rehab on 2-13, so that lab result then I have, even though it's in a separate part of my progress note, it's going to be from that previous review, so I don't get to count that again, but the labs that are for today aren't part of that previous record review, so I get to count those as two unique labs and then we have this whole list of diagnosis that we had to deal with. Now, my question is, what I'll try to do as a coder, I'm going to go through every one of those and say, did you manage, evaluate, assess, or treat these conditions, because those are the only ones I can count towards that E&M level, you know, if you were dealing with something with, let's just say, a wound, I would go back up and even say, well, did they examine the wound, and then that way I know that you evaluated it, so I have to make sure I'm only counting those conditions. So, now, this plan is a little bit problematic, you can see in gray, these are words, now this is a visit I evaluated, I mean, so are you doing it, you're not doing it, did you consider it, but how come you're not doing it, and so, you know, meds reviewed would benefit from reduction, so does that mean that this condition has improved, I would think so, but it would be nice if my provider would convey that to me. Hope of tapering, so what was the consideration on this, you know, that we were going to taper off that drug, so I don't have to give you credit for prescription drug management or not here, just because of the way that it's worded. Now, I added what you see in red, because I'm trying to convey what it is I'm looking for, AFib, rate controlled, then they give me the drug, on reduced dose of Eliquis, continue meds, so that's what I would be looking for, that's what I need you to tell me to give credit, so I know the status of it, it's a chronic condition, it's stable, and I have prescription drug management here, so that's what we need to see, then you go down to the CHF, what's the status, I don't see any med management, if by chance you were wanting to continue, then I've got this, could discharge the metformin, possibly discontinue it, so I'm going to assume that this is chronic and at goal, and then on the hypertension, what's the status, what's the plan, so again, I'm trying to categorize these for the presenting problem, and then I'm trying to go over here and look at the risks, so I need that information, those are your nuggets, your takeaways from tonight, okay, and then talking about the actions, we talked about that already, did it really occur, or needs to meet, you know, risk also includes decision making related to the need to initiate or forego furthering testing or treatment or hospitalization, so if you're not going to make changes, but yet you're thinking, maybe if you provide the rationale, maybe we can give you credit for that, so when I try to pull, put that together for coding purposes, I think there's a little bit more going on than possibly in a low-level type visit, so let's go to the moderate, and what I would be looking at is two or more stable chronic conditions that we managed, my data, we reviewed those records, and we also had a couple of labs, so I even got a moderate amount of data, and then I have my prescription drug management, so this is going to code out to a solid 99222 or a 99232 for that inpatient rehab, and it would code to a moderate level if we were doing a SNF visit, same thing, okay, so let's talk about time-based coding here real quick, we are now done with the greater than 50% counseling or coordination care, okay, we don't have to worry about that, I would like for you to get that maybe out of your smart phrases or your templates, okay, we don't need that anymore, it's the total face-to-face, or it is the total time you spent on the visit for that day, now you have to see the patient, so there has to be a face-to-face, okay, so there has to be the face-to-face, but it's the total time everything that you did for that patient is going to count towards it so face-to-face and non-face-to-face and regardless of the provider so if you leave in the afternoon and go to another facility but then you're taking phone calls and placing orders and all of that in another facility for the patient you saw on the morning rounds you can count that so you're even in a different facility and that's okay so it's all that time um but you want to exclude time separately spent on separately billable services and so advanced care planning let's say that or smoking cessation and so we would want to make sure that our documentation is clear so you spent 45 minutes the history examining the patient writing orders speaking with um with the cardiologist communications and and it excludes any time spent in separately billable services and i would highly recommend highly recommend that when you're doing time-based services that you put that very last sentence in there i'll show it to you again here in just a moment um when it comes to the um advanced care planning the oig last november put out a um an audit report and they got people first of all for not documenting time and the second one was because they were not being clear that the time spent in it was not included in other billable services and so it's important you understand that so i gave you a whole list of things that are going to count and so you can go back in and read those just a little bit later this is the time i'm not going to read all of this um out but this is how it's written down cpt the um so you can see the time that goes with each of your codes a couple of those have changed so be aware that you know of your changes prolonged care now cpt came up with prolonged code of 99418 for each additional 15 15 minutes on your visit and it can only be applied to the highest code in a category so your initial codes your subcodes it can only be applied to those highest levels and for this code it has to be only the time of the face-to-face encounter so the day of the encounter that's what counts is only on the day of the encounter and of course it can be bedside or on the unit and floor and then you would want to document what time that took and then they gave you this lovely little table and you can find this in cpt it's it's easy enough to get a hold of and to me it's pretty straightforward so this is according to cpt why i keep saying according to cpt is you know our friends at medicare they had to make things just a little more difficult so medicare came up with a g0317 and a g0316 so this is the 317 for the nursing facility visits and it again also says it's for 15 minutes but that will mislead you because then they go on further to say well but we but we have it laid out in this time file and i have a picture that's here in just a moment now here's what's so important this is the day before you see the patient so if you're going to go through all those hospital records and prepare to see that patient in the nursing facility setting if you're going to do that you get to count that time and then it's the day of the encounter and three days after now i think that sounds wonderful capturing all that time three days later might be a little bit more difficult you're going to have to have a workflow in order to do that but i want you to know that it's an option out there now for the um for the hospital the the uh the 316 is for the hospital and it is on the day of the visit only the day of the visit you don't get to do the day before and the three after like you do in that nursing facility okay and now here's the crazy part so this is that timetable you need to know that if you're going to use these g codes in the inpatient setting you are going to need for that 223 initial visit you're going to have to have 105 minutes total to get to the 233 subsequent you're going to have to have 80 go down here to the nursing facility your 306 you're going to have to have 95 and to do a subsequent you're going to have to have 85 and in the final rule the federal register they explain how they came up with this and it's kind of like i can follow it do i agree with it does it make sense i'm not necessarily sure it does but it is the rule it is critical that you understand this and to me it is not really well advertised if you want to say from medicare so i'm afraid that they're going to be setting people up for failure if they're not aware of this um discharge services the only thing i want to say is it has to have a face-to-face you need to document that okay so an exam will get you there otherwise language that says you had a face-to-face with the patient and then document be precise please be precise on that um don't just default to the cpt threshold for every time-based visit i think you're going to have some challenges under audit for any time-based services when you just simply default that for whatever the code was you just put down that was the time okay and don't forget on those um on uh those 309 or 99239s and a 316 it's more than 30 minutes more than 30 minutes and you better have that documented or we're not going to be able to bill it to that level um advanced care planning i already talked about that just a little bit i'm not going to go into detail but you've got to document that time and you want to make sure that it's clear to the reader that it excludes any other separately billable time and then i'm kind of giving you right here just some quick little um language blurbs that that i recommend that you use and you can go back and take a look at those later so here's some more of the green fonts here um letting this provider know this was the 306 and the prolong that g-code um for the SNF setting and it was well documented initial comprehensive assessment um detail support the time-based visit along with the prolonged and then i just wrote the reminder for medicare um starts the day before and all of that now if this visit had been based on medical decision making i'm letting my provider know if it's on decision making versus time these notes are excellent for data credit for discussion with an independent historian so that provider did a really good job of documenting that um sorry about that here we go and then um there was a partner review systems and i want you to know that there's a medically appropriate exam the admission labs so we get data credit for the cbc and a cmp um if coding on decision making so um uh would count because we didn't have those embedded in any kind of previous records and then also we get data because we're going to be ordering some labs as well so diagnosis assessment plan thorough assessment plan if we were coding based on decision making it would be easy to distinguish between acute and chronic and the status of the conditions was provided for most of the conditions and then prescription drug management was well documented and then i just went back and highlighted exactly what it was i was talking about so great note really great note um if decision making on a comprehensive visit maybe consider adding a notation when applicable that would assist in meeting that high complexity as far as multiple morbidities requiring that intensive management so maybe you want to adopt some language as detailed above the patient has multiple morbidities requiring intensive management that might be an option for you to kind of capture that reader's attention and then you can see here where they documented their time of 98 minutes and again get rid of that blue statement about the 50 counseling coordination of care so 98 gets me the 306 also gets me my g code unfortunately if this would have been decision making take a look at this this actually would have coded out to modern we would have had um even though our presenting problems would have met that high complexity my data wasn't extensive and my risks with my treatment plan were not extensive this would have coded out as a 99 um 305 not a 306 as you might think that it would okay so really start thinking about time with them removing 50 counseling coordination of care is time the better descriptor for you now maybe it is so let's take a look at one more and i think we're going to wrap it up here um subsequent uh rehab visit here so um we said that the hpi or that history sets that tone for the visit and it seems like this patient's improving according to the visit so i'm kind of already thinking maybe low to moderate something like that by the history i don't think this is necessarily going to be a high complexity visit then i've got that physical exam again so now these histories and these exams are just simply medically appropriate and that's all i'm looking for as far as um from a coder perspective and then i have an assessment plan so the coder or the auditor will determine according to the documentation what was managed evaluated assessed or treated so that i can apply them to the problems addressed so all the below can be used and are reportable diagnosis codes when um when we also look at that plan on the next slide so we've got that cva that we're dealing with we've got the cancer now it's an unspecified location so i'm just coming back and saying hey was it the colon you know because we always want to document and code to the highest level of specificity of course um they did have that hemicolectomy there um we could add knee pain shoulder you know dvt is it neoplasm pain so we were dealing from the history and then from our plan on our next page we could be adding pain here um and of note then there's a specific neoplasm pain code we would want to add the blood pressure you know the hypertension it just says blood pressure is controlled so is it hypertension you know are we going to continue the current regimen what about the diabetes you know the diabetes so is that with hyperglycemia um because in the plan they called the provider called it uncontrolled so if it is we would want to document it again to that specificity and we would want to make sure that we give credit for that type of a presenting problem so the plan is we're going to increase the lantis there so you'd want to think that it's maybe not controlled but we really need that we need that provider to give us that level of detail and then the dvt we're waiting on himong for recommendation man i think it's also pain related according to other parts of the note um and then the physicians continuing lovinok so again you know we really were evaluating these and we were treating them and so we want to include them in there and so then here's the rest of that note there where you can see continuing the aspirin h. pylori cocktail there's that blood pressure controlled you know we're going to continue that pain medication you know we've got um several different causes of it there and um so we could spell those out a little bit more um we've got the gi bleed you know so all of that gets that problem addressed and then we look at that data and then we look at the risk with the provider so it's going to code to a 99232 i'll show you that on the next coding grid because we've got the problems addressed are going to be moderate don't have to have any data that's okay and then we look at our risks so we said um two or more chronic stable illnesses maybe we've got a chronic illness with exacerbation maybe on that on that um blood sugar and then we said we didn't have any oh i'm sorry we didn't have any data um and then our prescription drugs what do we end up with we have a moderate type of visit on that so um i'm hoping these kind of illustrate just a little bit more for you so we talked about problems addressed at length and just make sure that are they chronic or acute and if they're chronic are they stable or are they worsening um clearly describe your plan and for your prescription drug management don't forget we need to have that action on there um and data points i i encourage you again to go back through the guidelines and kind of read through that a little bit more and say hey i do that i just didn't know i would get credit for it um document your time precisely and then demonstrate time on separately billable um is distinct from other time-based services and i apologize i know that we were going to try to get through that i'm about four minutes long on our 10 minute q a so um if we can carolyn and dr shapiro we can just get to our um a couple of questions i think thank you so much you did cover a ton in a very short period of time i'm going to characterize a few other questions um and group them together so there have been a few questions on defining bodily function uh when discussing significant threat um does it include bowel and bladder dysfunction and how would you address something like spasticity which could have very severe impact on someone's fall risk their pain and risk for contracture yeah on the bodily function i you know and i'm almost going to look to you dr shapiro from a clinical um perspective as well i i would be yes for me i i'm thinking yes i would answer that as the bodily function the bowel and bladder i i definitely would so um i i'm trying to think of a really good example and maybe you have one that comes to your mind right now i would certainly think like if someone was having difficulty with their with neurogenic bladder and bowel particularly if they were at high risk for you know sepsis because they're immunocompromised or maybe they have a spinal cord injury and have autonomic dysreflexia the risk would be significantly higher than it might be in other individuals and i would give myself more credit for managing it in that kind of scenario yeah yeah i would agree i would agree thank you i appreciate that and then what was the spasticity that was a question yeah i'm so clearly that's something we manage a lot in inpatient rehab and if it's not appropriately managed it can have long-term consequences for the patient i don't necessarily tend to consider that very high risk but um certainly if we were adjusting a intrathecal baclofen pump and someone was maybe too sedated that would be a higher risk scenario or if there were signs of withdrawal that would certainly be a high risk scenario as well i'm not and i'm not really sure how the how the person asking the question if they're saying well do do i use that in my problems you know my problems addressed you know is that like a moderate complexity problem address i don't know if that's where they're going with it or if they're saying over here you know do i get to consider that when i'm prescribing that medication and it's a comorbidity so to me that comorbidity directly impacts your decision on those medications we can't give this or we can't go to that level where maybe the patient needs to be then that would would contribute to that risk column i hope i answered that the way they were they were asking for um this is a great question time-based billing seems so much easier will it look strange or cause heads to turn if we just make all of our notes time-based well you hear that it does you hear that it does but there's part of me and i've been privileged enough to shadow providers um through through their rounds and i'm thinking time-based it's so often time-based that you know the phone calls the conversations you all have amongst each other you're going into the physical therapy and just having a conversation with the therapist you know your family conversations and it contributes to the to the care of that patient and there's so many of these can be time-based do i think every one of them is going to be time-based i don't think that that would be appropriate um but something to keep in mind too is that you know they they're still supposed to be still supposed to be aligned kind of with with a certain amount of time and so then are you billing for more time that's really been feasible in a day so um that's also kind of another question to have i've actually had that happen on somebody a few months ago when i got their billing report just like visits to do an audit like this person's actually building more time than there is in a day not that they were doing time-based coding but all of their codes were coming out as a high every time so they were back actually building for like 22 hours of work in a day um you know so you have to be a little careful about that but i i don't know yeah time-based i just think it's wonderful it's like it just captures everything that you're doing now much better we have a few questions on taking credit for reviewing data from other members of the rehab team like therapists nurses um potentially consultants as well like internal medicine um do you have any recommendations as to how people can best take credit for the those kind of conversations and coordination of care yeah well if it's conversation just document it as a discussion you know so and then who that discussion was with and again that's why i was saying that with the decision making you know a lot of times i know that providers were going into into pt and ot and having those conversations so document your conversations and then um on your notes you know is as long as it's from what i understand is reading like through maybe your therapy team's notes or the nurse's notes within your own within that facility right now right there i don't think that that necessarily counts it's supposed to be more of like um like outside notes or of somebody from a different specialty so that might be something maybe we want to follow up on just a little bit to make sure so um just going through the care team notes i'm not sure that that would really necessarily count um towards your data points that's a good question um lisa maybe we can get back with the with the group and almost do like some q a after this session and put it out there um yes i'm gonna make myself a brief note on that okay that would be great we have a few questions on that yeah and i know we're just about out of time do we have time for like one or two more questions and then we'll uh compile these and try to get out more information to our members um so there were a few questions on co-management particularly with internal medicine um and specifically one question said can you document that you agree with a medication change as prescription drug management or if you agree with ordinary ordering a test okay so this is me speaking and i would think so i would think so but that might be another one of those really good ones we do just a little bit of research on before um because to me you would still be dr shepard you'd still be saying well yes the patient is experiencing this or that and so i do believe that that would be appropriate so see to me you would be i would think that it would count but i'm not sure i've had that post yet we have to remember you know this is still march 21st and a lot of this is still new to us and so we're still coming up with with some of these scenarios you're like oh i haven't read that one yet haven't encountered that one i think that's a really good question i like that one so for the test i my opinion is yes but that's just my opinion all right so so i guess we have time for one more and and then we'll uh try to answer everything in written form um so i recently i'm just going to read the the statement i was recently told by a coder that for time-based coding that i need to specify exactly what was done for the visit is this true accurate is it no longer appropriate to document such as greater than 45 minutes required for initial visit including face-to-face with patient chart review discussion with therapy discussion with nursing as a templated phrase um i'm always going to tell i'm always going to tell a provider you need to get the case specifics in there so we don't have to worry about that whole 50 anymore remember the counseling and coordination care that can go away and then to template and say i spent greater than 45 minutes i'm also going to steer you away from that and i want you to be a little more exact so i want this one to be 45 and want that one to be 55 you know so you don't there's no clock start and stop time by any means but again i think under audit you lose credibility when you simply default to a cpt threshold for all of these you know and even me as a patient here recently i was like i had a question about one of my providers it was like every time it was 30 minutes i'm like are you sure because 29 would have only been a you know would have been a lesser charge and so you know but but it lose credibility to me and since we do um i work with so many providers that are in trouble for a variety of reasons you know copy and paste get you in trouble just using templates will get you in trouble so you need those patient those patient specifics now do you have to sit here and detail absolutely everything no you don't but just say you know extend amount of time discussing with family um you know coordinating with the care team so give me you know give me three or four specifics for the patient bullet points for the patient you know at least we're getting ready for all that fluff from the history don't have to do that big old exam and everything to get us to the code that you deserved right so we get to let go of that but really focus in on that decision making you know really really beef that up um but if you're doing time-based then just bullet points so that it makes sense to me like oh okay when i read that great well thank you so much we unfortunately well we got a ton of questions and i've tried to answer some of the simpler ones as we went along but we'll get back to everybody and also if people have additional questions after tonight's event um please feel free to to get a hold of us if you post it uh even in the inpatient or or inpatient consultants um uh phys form groups um i'll be looking out for those as well and can pass those along for for additional um uh information from our experts um thank you all so much for participating tonight and thank you linda for a wealth of information thank you i appreciate it

Linda Duckworth

evaluation management coding

2023 changes

inpatient rehabilitation

nursing facility settings

decision-making process

documentation requirements

severity

chronicity

drug therapy

hospitalization