Good morning, everyone. Thanks for waking up early today to talk about inpatient E&M coding guidelines. I'm Lauren Shapiro. I'm very happy to be able to introduce our amazing speaker this morning, Linda Duckworth, who is our billing and coding guru from Ventra Health. So we're going to ask her to take it away. Thank you. Thank you so much. Can you hear me okay out there with the lavalier? Okay. I was thinking so. So I'm with Ventra Health and actually on our consulting and advisory division. So what I primarily do is I do work with physicians or providers, try to on a proactive basis, meaning that we do documentation and coding reviews. And that's certainly something that I would strongly encourage you to do if you're not already doing that, because it's great to have somebody from the outside looking at your notes, evaluating your coding practices, giving you that feedback, because you would rather hear it from me than from one of your payers. So I spend a little bit of my time doing proactive, and then unfortunately probably more time on the reactive side. So I do work with providers who have found themselves at odds, and typically with Medicare, and even to the point of we do help out with criminal defense. And so it's kind of nice that we see that side of it. Then when I'm meeting with somebody in a proactive way, I can say, and that's going to be a challenge because I've actually seen it. Now it's hard to draw a little bit off of those experiences this year, because right now we're not seeing yet a lot of those problems hitting, because those changes just took effect in January for your area of medicine. Now we've been working on the outpatient side for a couple of years, and so we've already seen a few of those challenges, but there's unique things that are going on in the inpatient setting. So I'll try to share some of those experiences with you, some of the challenges that we've seen. But again, you want to stay abreast as much as you can of all of these changes. And hopefully you all are in here and you realize we did have some significant changes at the first of the year, right? And if you didn't, that's okay, because we're going to go through those. So I'm still surprised sometimes how many people don't know what took place. We've still got people in the office setting that don't know that they're getting ready to start into year four of these changes. And I can tell by the way you're documenting sometimes that somebody hasn't had those conversations with you. So let's dig right back into this here. Just a quick disclaimer, CPT codes, of course, are owned by AMA, and we're just going to have some brief references to them. This is not by any means meant to replace a CPT book. And I do have quotes from the AMA in here. I've got quotes from CMS in here, and I want to make sure, or I'll try to do my best to say this is how my interpretation is, this is from my experiences, versus here's a quote from AMA or a quote from CMS. I think it's very important that we're going to distinguish between that, okay? So again, some of our biggest changes that we had. So instead of our history and our exam and our medical decision-making, we are now going to look at just the medical decision-making, and that was restructured, or our other choice is going to be time, and I'm loving the time changes. I thought they were fantastic the way they did that. So getting rid of the history and the exam. And so again, we're seeing so many of the providers in there, and I'm still seeing them out there going a complete review of systems or a 14-point review of systems. You can get rid of that. We don't need that. And from a liability standpoint, you need to get rid of it if you're not doing it, okay? So so glad to see that go away. We don't need to get that family history on that 86-year-old patient that's coming in after having a stroke. You know, so all of that junk, that fluff, is gone. So you really need to focus back in on what's relevant to today's visit, whether it's going to be your initial, your H&P, or you've got this nice built HPI coming into your note or an interval history. So all the AMA said is just get a medically relevant, appropriate, excuse me, history or exam on these patients, and you're good. So that's really hardly ever a problem, that I would not have at least a history or an exam to some level. So we're pretty good on that. Now the thing is, though, I don't want you to completely think, oh, well, I can get rid of my history and I can put a couple words on there and move on. I encourage you, okay, I encourage you from a coder's perspective, from an audit perspective, to not overlook the importance of that history, that HPI or the interval history on code selection. Because when I'm looking at your note and I start reading that note, I have a good feeling for what's going on just by your history. I can think, oh, wow, this is going to be, oh, this is really bad. You know, or sometimes you're like, okay, this was just more of a weekend follow-up, patient's doing well. And so it just, already it sets the tone for the visit, okay. So certainly if those patients are not progressing as you would like them to be, or they have any kind of new problems, I really want you to tell me about that in the history. Because even though we say the history is not part of code selection, it influences code selection, okay. So it does. It gives me a good feeling for what's going on or taking place. Or sometimes I'll even scroll to the bottom, like, oh, I wonder if this is going to be a time-based visit, you know. So that's how much just impact it still has. So it's really just writing still a good HPI or that interval history. And certainly, again, if there's any problems going on, that patient's not at goal. So we're looking at the complexity of the problems addressed now. Because remember, no, we don't have to worry about the history and the exam. So we're going to look at those problems addressed. So we have now gone, and you'll hear people talk about COPA. So it's the complexity of problems addressed. Then we're going to look at the data that you're having to go through. And then we're going to look at that risk with your management decisions. So this is, to me, a really good way, an overview. This is how a coder or an auditor is going to approach your note. What they're going to do is they are going to look at every condition that you are monitoring, evaluating, assessing, or treating in today's encounter. And they're going to take each one of those. And then they're going to be looking at this first column on the problem addressed. And they're going to see how that aligns with low, modern, or high, the way that the AMA has defined it. So each one of those, they're going to plug it in. So I have a tool, a coding tool that I use. And so these are little check boxes for me. So I take each one of them. I come over here and go, oh, well, this is a chronic problem. That is stable. This is one that is maybe worsening, you know, exacerbations, and I can click the box. Then I go on to my data. So then I look and see, what did you order? What did you review? Who did you talk to? What did you interpret? And then I can click the boxes. And I'm going to give you credit for all of that data. Then I'm going to come over here and I'm going to look at your treatment plan. What medications are you ordering? Are you ordering any procedures? Are there any diagnostics that you would be doing that would increase risk to the patient? So each of those conditions, going to look at your data, the complexity of the problems addressed, and then I'm going to look at your treatment plan. So if I'm thinking about that COPA, that first column, the complexity of the problems addressed, and I'm trying to, as a coder or an auditor, see how I'm going to score those, again, either you're going to have to describe that condition for me in your assessment, or I'm going to have to pick up on it from the history. So maybe you just said COPD, but I can look back up in the history, and then you've got a really good description of what's going on, and it's worsening, patient's increased shortness of breath, or whatever that may be, okay? So you need to make me understand what's going on with this patient. So a little bit of a trade-off. You know, we got rid of the history and the exam and all of that fluff, right? But you're going to have to bring up now your assessment and plan. And it really is, again, representing that work that you did. So I don't know if your documentation load really was lightened as much as AMA kind of was leading us to believe. It's just that we shifted it, and there's a different focus on it. So there's pros and cons in this. So I know that's a little hard to read, but it really is the AMA table that we just kind of squished up, and we use it. It's a nice PDF. My email is at the end of this. If you want a copy of it, just email me, and I'll just send you, like, the PDF of it, and it's much easier to see. So anyway, like I said, we're going to look at the problems addressed, and I'm going to pick a level on each of those. Then I'm going to move over to your data, and then I'm going to move over to the risks with your management decisions that are being made. And two of the three on those is going to determine my code. And it doesn't matter if this is an initial visit or a subsequent visit. It's the two of the three. And so if I'm meeting high complexity in two of the three, as you see on that row below, I end up with that high-level code. So that's kind of the mechanics of it, and now we're going to kind of get more into the details of it. But if this might help you, say, oh, this is how they're doing it. So this is how your coders or your auditors are doing this. So looking at straightforward, I'm not going to spend a whole lot of time on here, but there's a straightforward. Straightforward and low share the same code, the ones, the 2-2-1 and the 2-3-1, okay? They share that same. And so it would be, if we're talking about straightforward, this is hard for me to come up with an example for you all. But you have to remember these guidelines were written for every specialty out there. So if I was doing maybe a family practice, no problem. I'm sitting here in front of you all going, I don't know. I don't know. So what I could come up with is possibly, you know, nursing asking you to maybe just take a quick look at a rash in between your typical visits. And you're saying, well, you know, it looks like a dermatitis, and quit using that perfume lotion that your family just brought in for you, something along that line. So that's your good straightforward. Again, so I'd be looking at your problems addressed, and I'm going to have any data on something like that. And then what's the risk with that management? It's probably going to be straightforward, minimal or low. So we jump up to the low, and now this is where we start to see, and it's blown up a little bit, like the table with the colored columns I just showed you, this is what it looks like. So this is actually being copied in from the AMA. It's very easy for you to get a hold of the whole set of guidelines that were produced by the AMA. You can just Google search AMA 2023 coding guidelines, evaluation and management, and they're going to pop up for you. And so anything that we talk about today, if you're thinking, I want to go in and read that again, just go Google search and pop up, and you're going to find that information that we covered today. So here's the column on the COPA here. So you can see we've got stable chronic illnesses. Is it an acute uncomplicated type of illness or injury? Stable acute illness, acute complicated? You know, so here's your choices on more of these lower level codes here. And then we look at the data. So the data, we're talking about tests or documents that are being analyzed or ordered during this encounter. And then we jump over there to the third, and I'm going to look at the risk with the management decisions. Let's bump it up to moderate, and in the moderate, you can see now you've got chronic illnesses with exacerbation or progression, those that are not at goal. You're trying to get them to a certain point, and they're not there yet. So maybe they're even getting a little bit better, but they're not where you want them to be. They're going to fall possibly in this category. So two or more stable chronic conditions. So this is where I was saying that from that history perspective, if it's not really well laid out in the assessment, I might be able to go back up and pick up from your history what the status of that condition is. So again, it has that influence. You've got undiagnosed new problems, uncertain prognosis, probably won't crop up too terribly often, I don't think, in your setting here. Acute illnesses with systemic symptoms, so certainly going to be your COVID patients. Also when we say systemic, they're also saying if it's maybe, here's how I interpret it, patient has a stroke, and then they've got the sequelae going with it, maybe that might even fall into this situation here as far as with the systemic. So it's really just saying it's also affecting other systems to get to that level. And then you can see now that our data starts to increase. Our data options we have out there increase, because we're thinking about a little bit higher level of patient than we were with the low. So the category one, we're talking about tests and documents, independent historians, and this is where we need you to make sure that you're documenting everything that you're doing. And so what are you ordering for the patient today? Because I'm going to go in and say one lab test, two lab tests, there's an x-ray. And so each of those that you're ordering, and I need to see that. So if you have more of a situation like daily labs, doesn't really help me any, because I actually get to give you credit for all of those that you're ordering, individual lab tests that are defined by a CPT code. So if you just say daily labs, you might not be getting the data credit that you deserve for all of those orders taking place. So you do need to put that in there. Now, if I am pulling those records for an audit purpose, you know, appealing or defending, we're going to go look at all your nurse's notes. We need to go see that, because then maybe I can come back in and say, yeah, but look at everything that they ordered that they did that was not in their note. But here it is. So it's important that if you ever submit records for audit purposes, that you have somebody that's really well-versed with the coding guidelines, so they know everything that they need to pull. I'm going to say that's probably the biggest culprit of not winning an appeal is not getting the right records sent in. Yeah, interestingly enough. Everybody just hands it off to a records clerk and says, oh, here, copy the notes. Not a good idea. Maybe if it's just one isolated incident, but anything more than that, you need to have somebody with knowledge doing your records release. You really do. Okay. So back on topic here, I apologize. So independent interpretations of tests, you know, so if you by chance are looking at that chest X-ray or EKG or whatever that may be, and you're doing an interpretation, this is your thoughts on it, do a little, you know, put a little ditty in there about it, but make me understand it's you. Those are your interpretations of that actual image or tracing, okay? So if that takes place. Discussion of management tests or interpretations. So if you're having discussions, you're having discussions with other qualified healthcare providers. So you do have to talk with infectious disease, cardiology, the wound care, you know, whatever it may be. Those discussions, you need to document them because it actually jumps up and it's a little bit more weighted than simply ordering a lab test, okay? So all of those discussions make me understand it. If you say cardiology consulted, I don't know what that means. Did you put in an order to have cardiology consulted or do you mean you spoke with that cardiologist? So it's so critical that you tell me that this was a conversation or some kind of instant messaging back and forth within your system, whatever it may be, but it's not just reviewing their notes, okay? So that's a different thing. If you're reviewing their notes, that's more of a, like a review of the, of external notes, okay? That's not a discussion. So make sure that you get that built into your language when that is taking place. So that's a category too. Or you can have, let's see, independent interpret, yeah, okay, sorry, I did catch them all right there. So that's going to be those moderates. So if you've got moderate data. And so again, maybe your problems addressed is up there, maybe your data is up there, but maybe the risks with your treatment plan aren't necessarily moderate, you would still get that moderate code because you'd be meeting the two out of the three, okay? So that's what we're looking for, getting those details in there. On your moderate risk here, you can see that they're telling you maybe minor surgery, regarding elective major surgeries, probably not going to be doing that with this setting, prescription drug management, everybody's favorite is prescription drug management. So we'll talk about that here again in just a moment. So, or a diagnosis or treatment significantly limited by social determinants of health. Does that ever come up with your group of patients? All the time, all the time. So tell me, tell me about it and tell me how it impacts your decision making, okay? So the patient's not going to have the resources when they get out of here and you're worried about them not getting their medications or that outpatient treatment or whatever that may be, tell me about it, okay? When it's part of your decision making, don't just carry it forward for every note for every day and think, oh, yeah, we're going to get credit for this every time. Be a little bit careful with that copying forward information without editing it. But anyway, it has to be part of your decision-making, so tell me about that. Let's jump up to these highs. Everybody loves the highs, just because, of course, the reimbursement and the amount of work and complexity of some of these patients. But, you know, this is how the AMA came up with it, okay? So when we're trying to, remember, thinking back to the colored grid, so I'm the coder, the reviewer, the auditor, whatever that may be, taking those conditions, each one of those that you monitored or evaluated or assessed or treated today, and I'm putting those into that COPA, the column, right? So do any of them line up with one or more chronic illness with severe exacerbation or progression? And very well could be, coming in even still from the acute state, you still might say, hmm, no, this is where they align. Or is it an acute or chronic illness or injury that poses threat to life or bodily function? Okay, so that's what the AMA is saying. Typically, these types of patients coding to this level, their problems addressed would align with one of these. So again, how am I going to pick up on that? I'm going to pick up on that from either maybe your history, but hopefully from your assessment or your plan, okay? So it's all in the detail on these patients. Then we want to see extensive data. So I want to see two out of the three of these categories, meaning, is it going to be your test or reviewing external notes? So I did have a physician submit some records to me, and I've got them here in just a minute, and I'm reading all about the acute stay. And then I'm wondering, well, is this like a summarization of those external records versus you just coming up with your own HPI? You know it's a review of the records, but you really need to put it out there so that it's clearly labeled for those that are reading your notes. It's a good idea that you do that when you're bringing that information in. So looking at review of those notes or results and ordering of the test, maybe you have an assessment that requires an independent historian. So when you have that husband, wife, child, parent coming in and either supplementing the history or they are providing the history because the patient cannot do it, the patient is unreliable, you need to make sure that I understand that's what's going on and somebody's not just chiming in with a few little details here and there. So independent historian, we can get data points for that as well. Category two, again, independent interpretation of the test or we can have discussion of the management with that other qualified healthcare professional. So we would need to meet at least two or three of those. So the data for what I'm thinking is to have the high complexity data. I think you're going to probably be okay with your HMPs with getting your test results, those kinds of things. I think that that won't be too difficult. But pretty much you can't be high if you don't either have that independent interpretation or discussion. Okay, if you got to do the two of the three, it's, I didn't write the rules, this is one of those, don't shoot the messenger. But that's pretty much how it comes, what it comes down to is you're not going to get high data without one of those two things happening. Your management decisions here, then again, you've got drug therapy, we're talking about monitoring for toxicity, decisions regarding elective major surgeries, probably not so much here, regarding emergency surgery, decision regarding hospitalization or escalation of care. You want to talk about a hot topic. That is the hottest topic probably with the guidelines that I know it right now. So I was so anxious to listen to the AMA the last couple of days before I came here, hoping that they would address this more. Because we've been working with it on the outpatient side and it was very clear-cut. It was one of those, if you're in the office setting, oh the patient needs to go, you know, be admitted. We're like, oh yeah, that's easy. But how does that apply to your setting? So they're coming from an acute stay and they're coming over here now to the inpatient acute, still acute, but this inpatient setting. So is my physician making the decision regarding hospitalization? And I would, I don't have the best answer for you. I kind of shy away from using that because we can't get them to really address it specifically. The escalation of care doesn't seem to fit necessarily for this setting either on those H&P initial visits. If you are going to send the patient back to the acute setting, like okay, they've got to go back there because, you know, the pneumonia now is worse or whatever that may be, whatever's going on, yes, yes, you're gonna get it. I feel very confident. I have no problem with that at all. But when you're just doing that initial visit, I would, I would not feel comfortable doing it. But yet I know that there's a lot of people out there that feel, you know, this is appropriate to this setting. So I don't have an answer for you on that. And I will, if I get something, because believe me, I am like a, I am like a dog with a bone on this. So if I can get the max, you know, your Medicare contractors to specifically address this for this setting, whatever. Carolyn and I are communicating throughout the year, you know, if you hear anything, you'll let me know. So yeah, but like I said, dog with bone. I'm not letting go of this. I'm gonna get that answer at some point. And then you've got like a decision not to resuscitate. So that's what it looks like on, you know, as in a table type format. So let's just kind of go through here. And there's those problems addressed. So just keeping in mind, when you're, we're talking about the problems addressed, I really want to make sure that you were, you know, it really was a part of your visit and that you were assessing this and somehow. So if you just throw in there that the patient has some issue, you know, tachycardia and maybe what the medications they are on. And then I don't see you talking about it. Are they, you know, compensated? That's a term I know that gets used a lot, you know, or is that well controlled or whatever. So if I don't see anything like that and I just see the diagnosis and maybe the medication they're on, diagnosis, cardiology following, I'm not really going to count that for my medical decision making. Okay. I don't want to do that. So really want to make sure that you've got something in there that says you really did assess this for it to count towards your E&M level. So evaluated or treated. So this, these first bullets are going to be taken directly from the AMA. And it also includes conditions where further testing or treatment will not take place due to risk. You know, so again, if you've got a condition out there that you are addressing, but you decide that you're not going to work the patient up or the patient says, no, I don't, I, no, I don't want to go through that. I don't want to look at that. Even though that you find it very concerning, you would certainly want to document that. Sometimes I think those might be even trickier than the patients that are totally on board with what you're saying. So you want to make sure that you're documenting that. You're thinking that this could be a problem. This could be this type of an issue. And I strongly encourage the patient and their family that we need to get a CT, that we need to call in whoever. And they say, no, I don't want that. It's okay. You can still count that part of your medical decision making. Making a referral without personally evaluating. Again, if you just say, oh, you got to, you know, looks like we'll just have somebody else take a look at that. We're not going to count that towards your decision making either. So just limit the problems addressed to your current encounter. And it might even be different than the reason for the ambition. So one of the examples I gave is maybe that patient was actually brought in for CVA for their rehab process. And then maybe at some point they have some complaints of some urinary complaints and you get called in to go see them in between your other visits. And you just address that. We're going to have a limited visit. And we really, unless other stuff are going on and you want to take the time to evaluate the other stuff, it just might be simply that you're putting down that urinary frequency or the UTI or whatever that may be. So again, we're just looking at what happened at this encounter. Help me out here. Document chronic versus acute. So back pain. If you put down back pain, I don't know if that's acute or chronic. And remember that table and I said us coders and the auditors, we have to take each of your conditions and I have to know is it acute or chronic. I have to know that. Now I'm going to assume blood pressure, diabetes, so much of that is going to be a chronic problem. I'm good with that. But even depression. The depression might not be, you know, it might not be a chronic problem. Maybe it just cropped up because the patient, you know, has had some type of an event happen. And so it's really more acute at this point in time. So tell me if it's acute or chronic. I did review somebody a couple weeks ago and I was like, a little tear in my eye, because she actually took her conditions and she would say, you know, chronic. And she had it in there for almost all of her conditions. And then she would say, patient, is it goal or not a goal? And I was like, thank you. Thank you so much. Yeah. Because again, as a coder or as an auditor, they're going to come in and if it's not clear, they're going to go with the more conservative choice. Okay. So that's why you want to get those terms in there. So, you know, hypertension, blood pressures continue to trend upwards. So I'm going to go chronic, trending upwards. That is a chronic condition that is not at goal. And that right there would align with moderate. Okay. So I'm picking up on that. Maybe I got it from the history. Maybe I got it from the assessment. But it's in there. And then blood pressures, well controlled with lisinopril. And that's going to be like more of a low. Okay. So chronic. So the chronicity needs to be there. And tell me, what is the status of those conditions? Comorbidities or underlying diseases. Okay. The way the guidelines are written. When we're talking about risk, it's your management options. So as I believe it to be defined, that is going to be, again, this is going to be your, are you ordering a diagnostic that would put that patient at risk? Are you doing any kind of medications that would put that patient, you know, at risk? So it's really that treatment plan. And not the medical condition. So the AMA talks about that in the guidelines. And they're telling you it's two different things. Maybe you'll align sometimes. Maybe they won't. So we can't go in and say, but for my risk, this patient is coming in from the acute state and they still have this and this and this. I gave you credit for that in the COPA, the problems addressed. We don't use it for risk in the risk column unless you tell me that the patient is maybe needing some IV fluids. And then you put in there, you know, got to be real careful because this patient has CHF. And so we got to be super careful about our fluids. Or maybe you want to give the patient something more like an over-the-counter medication, but they have issues with, you know, with renal problems. And so that is a different story than if you gave me fluids or if you gave me some over-the-counter medication. Okay? So for me, those might just be low. But you take a patient that has a medical history or condition that it changes that medication, changes the diagnostic, changes a procedure, then tell me about that. And then we can bump it up. But I don't just look at a diagnosis and go, oh, that's a high-risk diagnosis. Mm-mm. Mm-mm. So when I'm writing to whoever my audience is, my providers, and I'm giving them feedback and I'm doing this, I'm going, here's your COPA. Here's your data. And here's the risks with your treatment plan. And that's how I'm doing it. And you're not going to see under that risk the patient has, you know, COPD exacerbation. That's not going to be it. It's going to be what did you do for the patient. Okay? So it is important that we make that distinction. And again, it is in the guidelines. And they tell you that they are different. And they even brought it up on the call the other day that we have to be careful that we're not looking at those conditions and trying to throw them back into the risk column. Am I a fan of it? Did I write it? No. No. Not at all. We were having a conversation right before this session started. And I said, you know what? I love what I do. But anymore, I kind of hate the fact that my job exists. I just, I really do empathize with all of you. It just, again, I was saying, everything you have to know, and you're supposed to know what I know on top of it, it's a little bit ridiculous. So I really do sympathize. And I don't want to make anything harder on you. If anything, I want to make it a little bit easier. If I can get you in the habit of just picking up on some key terms. Oh, I need to maybe make sure and start doing that. Okay. I didn't think about it that way before. So just getting you to recognize all of this that can be going on and the work that you're doing and getting that into your note, that is really the point of what we're doing here today. So that's the comorbidities. And then if we have a diagnosis, symptoms or the final diagnosis can be used. And so one of the things, too, that, you know, if you've got something up here, and my emergency room physicians are notorious for this, and they'll put, you know, patient could, I don't care what it is sometimes, it's like, oh, but this patient could have meningitis, and they could have this, and they could have that, and they could have this, and they can have that. I'm like, or the five-year-old could just have otitis, too. But they're putting in everything that they're ruling out, you know. And so not that it's a bad thing, but if you're gonna sit here and say, oh, we need to work this patient up because it could be that they're having some, you know, really acute medical event, then I would suspect that you should be down there ordering, you know, the CTs or the labs or whatever that would go with that, you know. So that's kind of their cautionary statement out there. They're saying if you're gonna say that you're gonna rule something out, or it could be, then you probably should be ruling it out if you're gonna use that within your coding. Let's see here. Stable. Now this is a term. I'm not sure it was probably the best term that the AMA could have used, but they're putting the word stable in there because you all define that maybe just a little bit different. But when they came in, they said stable for the purposes of the decision-making is defined by the specific treatment goals. Okay, so the patient's treatment goals. So that's why I was saying I need to know is this patient at goal or not at goal. You know, we do a lot of pain management. Me and my co-workers, I do some pain management. But that's one of those, some of these patients, what's their goal? You're never gonna get them to zero. It won't happen because of the diagnosis that they have. What's their goal? We want to make sure that they are able to participate in their, you know, their daily activities, that their pain is managed and allows them to be, you know, productive. That's their goal, right? So that would be their goal. So that's why we want to know whatever it may be, is this patient at goal? So again, they could even be, I think I said this earlier, progressing, but they're still not at the goal where you want them to be. So you need to convey that somehow in your note. So stable means the treatment goals. So conditions not stable even if no change and there is no short-term threat to life or function. The acute uncomplicated, recent or new short-term problem with low risk of morbidity. You can get an acute, let's say, let's jump to stable acute illness, a problem that's new or recent where treatments been initiated and the patient is improved. And while maybe resolution may not be complete, but they're going to consider that to be stable. A chronic illness with exacerbation or progression, so this is going to be more of like a moderate type visit here, a chronic illness acutely worsening, poorly controlled, progressing with intent to control progression, requires additional supportive care treatment for side effects, okay? So if you're thinking more in that moderate category, those exacerbations, you're going to definitely want to tell me about that. The acute illness with systemic, so causing systemic symptoms, high risk of morbidity without treatment, systemic general systems such as your fever and body aches and those kinds of things are probably going to be a little bit lesser. So again, you know, if you've got some kind of an acute illness with other type of manifestations, you know, bring that into your note and let me know that. You've got that complicated injury, evaluation of body systems that are not directly part of that injured organ, injuries extensive or the treatment options are multiple. So that might come into play too. And then again, we've already talked about this, so these are the high complexity, your level threes, whether they be initial or they be that subsequent. You're looking at severe exacerbation, not a bad idea. If you're thinking that something is a severe exacerbation, get that into your terminology in your notes if that applies. And then you look at the illness or injury posing that life to bodily function, poses a life to bodily function in the near term, in the near term without treatment. Some symptoms may represent a condition that's significantly probable. So again, this we kind of talked about this already, right? Those kind of rule out is where you're going. You definitely want to tell me that those other diagnoses that you're going to have to consider and try to rule out. And so then again, here you go, when the evaluation and treatment are consistent with that degree of potential severity. Okay? So again, you could have a patient with this chest pain or whatever, and then we work them off and it ends up being a bad case of GERD. And you're like, okay, well is my complexity of the problem addressed? Probably going to be high. Especially if you've got a patient with a history where it's, you know, quite probable they could be having some acute type event. So that data, the analyzed here, tests, images, labs, count the order in the review, but not both. That's right from the AMA. Okay? So we can look at, today if you're going to be ordering some lab tests, so you've got the CBC, the CMP, whatever that may be, you come back in the next day and you review them. I don't like this at all. I strongly disagree with it. But the AMA says, nah, we're going to give you credit for the order or the review, but you can't do both when that order and review was either by you or one of your partners within your group. So the same specialty. Now, if you're going to be reviewing something that cardiology ordered yesterday and then you're looking at it today, that's fine. Because you're not in the same group. But as long as you're all in the same group, they kind of treat you as if you're one, but you can't order the test and then get data points for reviewing it. And from a coding and audit perspective, it is, it stinks. Because then I'm trying to go back and go, okay, now I've got to look the day before to see if you're the one that ordered it or one of your partners. So then I have to know who's in your group. It's a mess. And I, and if I could, that's probably my number one gripe, number one gripe about that. And plus to me, in my opinion, those are two different things. The, you know, the thought process going in to what I need to order for this patient, the thought processes, then going back and reviewing that to me are two different things. And if I could encourage them at all to change something, that would be one of them. I don't like it at all. But that's the way it is. Count the order or the review, but you can't do both. Do not credit data points for separately billable services. So if you were going to be doing an EKG interpretation and you're billing for that, we're not going to give credit for that in our evaluation and management service. I'm not going to do that heavily weighted interpretation towards my data because I'm going to bill a separate charge for that EKG interpretation, if that would come up. Probably not too terribly often in this setting. Any kind of lab panels that you're doing, like a CMP, we don't sit there and look at every test result in that CMP and go, oh, look, one, two, three, four. We don't do that. It's just one test, a CMP. It's one CPT code, and that's what we're going to give credit for that. The data. So, so what do I, so what am I going to do? Am I going to give my physician credit when I just have results brought into the note? It's the chest x-ray. So you're able to go in and get that final interpretation or the full report from the chest x-ray, and you bring that into your note, or from the CT, or all of these lab results, and now I have like an 11-page note that I'm going through. So you're bringing this in here. Now, if I just drop that in there, am I going to be able to get credit for that? So the AMA kind of talks about this when they say, you know, we're talking about things that you've considered, ordered, planned, scheduled, performed. You know, they use the word analyze in there. Then they come down, and they say, a notation such as WBC elevated chest x-ray unremarkable is acceptable. So this is almost a little open to interpretation. Here's my thoughts on it, okay? My thought is on it, on this, is if you're bringing those test results in and you're not commenting, I don't know how that payer is going to see that. So I would encourage you that if you want to bring them in and you're thinking, I want my data points for this, that at least you make these brief comments as the AMA has given you as an example. They repeatedly said the last couple of days that they do not tell you how to document your medical record. They don't get into the habits of documentation and telling you what has to be and does not have to be documented. So that's the only thing that they said. And then they just said that those would be, you know, acceptable. And so that leads me to believe they're kind of thinking that if you want your data points, you need to make a comment on that. And I am sorry I can't give you this whole black and white, yes, no answer. So I just strongly encourage you to make some kind of a little comment on it if you're thinking you want to use that for your documentation, for the data. And they even tell you that maybe if you were just, you know, like initial report, you know, showing that you've read it, you know, so if you had a paper record and you were doing that. So to me it leads you to believe that they're thinking you should make some kind of a comment about those results. We talked about the unique test. Really it's defined by the CPT. So like your CMP, it's one, it's not a whole bunch, you know, of different ones. Unique source for information or discussion is defined by a physician or other qualified healthcare professional in a distinct group or different specialty. So again, if you're having those conversations with infectious disease, cardiology, whoever that may be. But we are, we had this conversation before the session started and it's a qualified healthcare professional. So I don't think that that's going to count. If you go in and have a discussion, you know, sometimes you're walking into physical therapy, occupational therapy, and you're having those discussions with that professional. But are they a qualified healthcare professional as defined in this setting? And I don't believe they are. I do not believe they are. So your, these are your nurse practitioners and your PAs. Who are the other people that we were saying that we thought would count was the, was it neuropsych? Neuropsych, you know, so really the people that can almost like separately build these types of services are your qualified healthcare professionals and not so much your therapist. And that's for your discussions, okay? You could review their notes and you can still get data. But going in and having those discussions, they're not a qualified healthcare professional as far as the AMA goes in this type of situation here. So unique source of information, the discussions, we talked about that. Review materials from any unique source. So if you're looking at that previous day, all of those records are really one source, a unique source from the previous day. Certainly any kind of outside records that you might have available to you. If you're reviewing that, you want to bring that, you want to bring that into your note and let us know that that's where that information is coming from. So sometimes, you know, like I said, I can take a guess. I'm like, oh, I bet this is from the whatever, you know, from, from wherever, another source. And it takes me a little bit to pick up on it. So let me know that that's what you're doing. The external records, communications, or test results from an external source. So again, looking for another facility, looking for records from another specialty. That's what we're talking about, okay? The physician or the qualified healthcare, someone not in the same group. Now let's talk about this discussion. That's the interactive exchange. Like I said earlier, you know, if you just said cardiology consulted, I'm not going to give that to you, okay? So if you had a conversation, you were consulting with cardiology, make me understand that and that is the type of work or what level that communication was. Now they say that it doesn't have to be on the same date as that encounter, but it's counted only once and only when used in the decision making of that encounter, okay? So not maybe the same day, but it is an interactive exchange. It's not just simply reading the consult note, which would be more of that records review versus having a discussion. So gotten a little bit of argument here lately about that one too. Independent interpretation, the independent historian, I'm sorry, provides your supplement. So I talked about that a little bit. So again, you need to document why this patient is not, you know, able to give you the history that you're wanting and whether it's their condition or, you know, they're just not reliable by any means. Tell me that. Who did you talk to? And certainly then what did they add to that history? If it's just an independent historian was used for the history, I'm probably going to go no, or at least I'm going to type back to you and say that's going to be a problem under audit. So you need to do a little bit more explaining who it was, what they brought in and why that they could not get that. Certainly don't use it for your translation services. It doesn't have to be in person, but it has to be from that historian. So if you had to make a phone call and get that, that's okay. That's okay. It's still going to count. Personally interpreted, we talked about that already when you're not billing it and that's more, it's weighted a little bit more if you will than if you were just going to look at someone else's interpretation. So the radiology, you know, and you look at that chest x-ray and that's going to be a review of a test, not an interpretation. So if you're doing it, you want to do, you would certainly want to let us know that's what's going on. An appropriate source for that discussion of management professionals not in healthcare, but involved in managing the patient. So they've brought that in too. Risk criteria applies to management options. So you can see I've got it bolded and I've got it underlined because I kind of hit this already because I think that there's a lot of, there's a lot of confusion with it. And so I have these physicians say it was so complex and they keep talking about the condition and the condition and the condition. And I get that and I feel that. And because again, we put that under that COPA, that problems presented, but what about the management decisions? The management decisions, what are you doing for that patient? And here's where the AMA kind of talks about this. This is distinct from the risk of the condition itself. Okay. That's their wording. It's distinct from the risk of the condition itself. And they came back in in 24 and pretty much kind of did the same thing. They changed up the wording just a little bit, but at the end they finish off by saying it's distinct from the condition. It might correlate, but the condition is distinct from the risk of management. Okay. So I want to make sure we're kind of clear on that. And then they talk about it's the risk is based on the usual behavioral and thought processes of the physician or that qualified healthcare in the same specialty. Risk based on the consequences of the problems addressed when appropriately treated. Also includes diagnostics or management options when not carried out. Kind of talked about this earlier. So you're thinking the patient needs to be worked up for something, but they can't be because of their condition. And you're like, well, you're weighing the risk versus the benefits of something, whatever that may be. And it's okay if you or the patient family decides not to go forward. It's still counting the work involved in that. So that's okay. And you would want to count that. We talked about the social determinants of health, economic, social conditions that impacts the health or ability to obtain care. So use that. We want to count it when it's part of your medical decision making. And it's well documented in there. I'm not going to go into the surgery here. Drug therapy, intensive monitoring for toxicity. So you've got some nasty drugs sometimes with these patients coming over from that acute stay. So if you're actually evaluating that or have some kind of, if you have the role in managing that and following that patient for those kinds of nasty drugs that they're doing, we can give you credit for that. So lab tests may be one way to say that you're going to be monitoring for that toxicity. So those patients that are on vancomycin or whatever coming over, they very well could end up in this category for those medications. Not for therapeutic benefit, but you're going to monitor them for the toxicity. NGS Medicare. So if you all are out there under NGS, a lot of the MACs, your administrative contractors, Novitas, Palmetto, WPS, whatever they may be, they'll talk about a lot of this. Please define prescription drug management relative to the decision making. In order to count that prescription drug management, there's got to be a prescription drug that the practitioner is evaluating the appropriateness of using for the patient or continuing to prescribe it. So it's kind of like you have to either assess the effectiveness of it and comment on it, that it's patients well compensated on, blood pressures are well controlled on, you know, something along that line so that we can see that you really did evaluate the effectiveness of that medication. So you've got that as an option. So certainly if you start and you stop it and you increase or decrease or you hold or you're continuing kind of thing, but that's what you're looking for. Now the continue, I'd certainly like to see if you're just going to say continue meds or that you put in there, again, that medication, the effectiveness of the medication and then you're going to continue it. I think it's better that you kind of get those words in there. So those are options for you. But really what they're saying is simply listing the medications the patient takes is not prescription drug management. So that's really just a drug list. So just making sure that you've got that in there if you're evaluating the effectiveness of that medication to be prescription drug management. Some of our documentation challenges, like on an initial visit here, bringing in kind of like an example here for you, initial visits, creating a paragraph summary of the previous day qualifies of review those notes. But I'd like to make sure that I can see that. So review external notes only. And there's some results in here. So you're thinking, oh, do I get to get credit also for reviewing these external notes plus the MRI and plus the CT? No, because they're all embedded within that one note review. So you really don't take them out and make them separate. So here's what that looks like. Previous slide, we said the patient was admitted on the 4th and then came into the rehab setting on the 13th. And I can see these labs right here. Well, that would be included in the records review. But then I'll jump down here and I say, oh, but here on the 13th, the date of admission, I've got some new labs. So then I can go ahead and count those. But if they're coming in from that hospital and part of that records review, it's just kind of a one bundled item. Do I like it? Not necessarily. Now, here's like a case study. Again, great, great history. You know, I'm reading this and I'm thinking, oh, this is just a mess. You know, this patient, not the note, not the note, but the patient, just quite the mess here. Complicated renal failure, I mean, on and on. And so I'm reading this and from a coder's perspective, I'm like, oh, this sure starts to look like a three to me. And so again, you know, now was this a review of notes or was this just something the patient, you know, or excuse me, the physician put together? Well, I think common sense tells us that those are external notes, but probably not a bad idea to label them that way. And then I'm going to take those test results and I'm going to bundle that in there. And then when I went further down from that HPI, guess what? Then I see this today, patient feels well. So I'm like, okay, I'm going to go ahead and give this person this review of records because I think that that's definitely what's going on here. But it wasn't labeled that way. And so I'm going to be generous and give it. Now, would a payer? I don't know. I don't know without clearly labeling it as such. Current labs more than there was like current lab here more than shown. I'm sorry, the orange did not come out very well on this, did it? Need a brief comment such as improving concerning for elevated trending. I'm encouraging you to do that. You know, so if they're just brought in, did they review them or did they just click a button and bring all this stuff in? I don't know. Is this provider ordering? I've got continue daily labs. Then we're going to check level on Monday, Wednesday and Friday. So are we ordering this? So if I'm trying to give you credit for unique tests, I don't know what those are. I don't know what those are without having access to the whole medical record. Now, as a coder reviewer, if I was getting into your EMR, I could go pull them off myself. But if you were to print these and send them into a payer, you're going to need to get those orders so that we know what to give you credit for. If you use any kind of an outsourced coding company, you know, you'd have to have conversations on how you're going to handle that. So going back in here and again, like I said, now here's my assessment and plan, the COPA, you know, so what exactly was monitored, evaluated, assessed or treated? So going to go into each of those that you see in orange and then I'm going to categorize them. I'm going to go back in on that yellow. I'm going to try to get you all the data, so the labs, looking for that, records reviewed, discussions, what all took place according to your note today. Then I look at the risks and is it going to be meds, diagnostics, got left off of there, I apologize, meds, diagnostics, procedures or decisions maybe regarding a hospitalization. So do I see anything like that in here? So that's what I'm looking for. And then if we, I had a teaching attestation. I had to throw this in there. It was a little bit of a gold star here on this one. So anytime you're doing in, and we don't have time to get into this, but if you're doing split shared, if you're doing teaching physicians, those attestations are awesome, but you need to complete them with some patient specific information. It really would behoove you to do that versus just sitting there and going and just stamping them. Yep, yep, yep. And so anytime you can customize that a little bit, throw something in there. But again, this was like a little bit of a gold star here. So really finishing it out with some patient specifics. That was awesome. And then without going into a lot of this, again, we're trying to stay E&M, but with the question did come up, what about your resident supervision, and at least during the pandemic, and now through the end of 24, you can do that remotely. So make sure your documentation looks real good if you're doing that in a remote, remotely. So document thoroughly on that, and there's some information out there for you. So the resident, this is back to our case study resident, and the physician, we're just talking about how this patient's gonna need this intensive rehab program. Their risk per that AMA guidelines, I already talked about this being distinct from the risk of the condition. So what does that look like when we put it out here? So I'm looking at, again, all of those problems that were addressed and trying to categorize them. And so with this very complicated patient, I'm certainly pulling the trigger on that high level, high complexity. I'm okay with that. So that first column there, my problems addressed, then I look at my data, and my data, discuss management or interpretation with external physician. Let's, we'll take a, let's see. Let's back up for just a second. Let's see here. On one of them, it says we did talk. Was it on this one? Sorry. We, yeah, I skipped over this. I do apologize. So here in the attestation, we did speak with transplant nephro who reported no need for the dialysis today. So going back in here, I was like, I know I've got this data point. So there was my risk. And then we did have that, discuss that management. And then I'm unsure about those labs because I don't know what exactly I'm ordering. And then there were some results brought in, but did we actually review them? As you know, there's some uncertainty here on that. So I might not be getting credit for the stuff that, for what actually took place. We've got that review of those external notes, but we still don't have high complexity data on this patient. And then, so maybe we're gonna be down here with the category three with that discussion. And then I go back over here with my management options. So again, was I ordering a procedure diagnostic, a medication or anything like this that's gonna be high risk? And it, according to the note, it doesn't necessarily fall in there. Now, some of the medications are something that we're doing. Did it increase the risk for this patient? Possibly, but it wasn't in the note. So I'm, you know, for me, this is gonna come back out to a, it was actually supposed to be a level two, I apologize. I thought that got fixed. So I'm sorry, but it actually would be a level two and not a level three. And it pains me. It pains me, but this is kind of how it's written. So data really comes into play or possibly time. So real quick on our time, because it just, it's not difficult. It is no longer difficult. So we don't have to worry about that greater than 50% counseling or coordination of care. So it is your face-to-face. It is the total time on that visit. And you could even be in a different setting. So you could do rounds in the morning and then in the afternoon, take phone calls, work on your progress note, what, you know, have those discussions with others, whatever that may be, and that's okay. So regardless of where you are now, you can go ahead and count all the time for that visit for that day. And that's probably one of the biggest and best things that they had done for us with these changes. So all of that is counted. And so you get to have those conversations with family, even if it's just a family update, that's okay. You get to count it. So everything related to that patient for that day gets to be counted, regardless of the location. And then of course, if you had any other separately billable services like advanced care planning or whatever that may be, some kind of counseling that you were gonna separately bill for, you would wanna make sure it's clear that it doesn't include that. So looking at those records, if you're doing time-based, obtaining some histories, medically appropriate, you know, examining the patient, doing your orders, referring and consultations, independently, you know, doing those test results, explaining results, you know, care coordination, all of that, everything gets counted. So boom, now I get to count everything. And now I can maybe do my time-based a little bit more. So your level one on your initials is gonna be 40. You're gonna have to go to 55 for your level twos, and you're gonna need 75 on those level threes. So the time went up a little bit, but they allowed you to count everything, and it used to not be that way at all. And so I'm glad to see that. Subsequent, I've just got the time in here. You're gonna need 25 on your level one, 35 on your two, and 50 on that level three. Prolonged, you can use this. At least CMS cleaned it up a little bit. They had actually went out and created their own times for prolonged services last year. Totally messed everybody up. They really, really goofed that one up bad. Then they went back and corrected themselves. Last summer, I think it was in July. Carolyn, do you remember when they went back and issued that correction? It took them seven months till people, I think, were up in an uproar. But it pretty much mirrors now CPT. So they're saying to do prolonged, it has to be on the day of the face-to-face encounter. So it's really nice now. You're gonna have all that time for your E&M, and then later in the day, you're getting those phone calls from whoever it may be. And you get to count that time, okay? So they're just gonna be add-ons. It's a fairly simple, straightforward table. This is right from CPT, telling you you would need 90 minutes to have your level three plus your prolonged for that initial. So it's nice. So if you're out there doing it, don't forget that it's available to you. Then you've got the, Medicare wants you to use their G-code. And again, with or without direct patient contact, you can be using this add-on. And again, it's only for the date of service. And now they pretty much align anymore with CPT. It's worth about $30 for each of those billing units when you go, for each 15 minutes that you go over. So those are available to you. I only wanna put this out there really quick. If you're doing your discharge, there's two things. You gotta have the face-to-face. So tell me. Now, if you're doing an exam, boom, done. We know that. That's face-to-face. But make sure that you can have the most glorious summary of a hospitalization. But I don't see that you saw the patient that day. Okay, so put something in there that lets me know you saw them. And then by golly, if you're gonna do that two, three, nine, you need to document your time. And I would strongly encourage you to get out of the habit of just saying greater than 30 minutes, greater than 30 minutes, and have that be a standard little ditty on your notes. It's always best to be specific with your time on anything like that. If it's the same for every single patient I review, it almost starts to lose a little bit of credibility, it seems like. So I encourage you, don't have to encourage you to do that. Advanced care planning, not gonna go into this, but it was time-based. I see so many mistakes with this. They're not documenting their time in there. And so if you're doing any advanced care planning, please make sure that you're documenting your time. And do review, it was a hot topic with the OIG. They had like a, oh, it was incredible, I think over 60% error rate with advanced care planning. So you need to be aware of that. If you need to, you can always email me afterwards, I can send you something on it. So anyway, just making sure we're excluding extra, those separately billable services. So let's look at this. So we're kind of wrapping it up here, okay? So we've got another case study. Sorry, this wasn't one, I was just, but this is another case study here. So this is awesome. If you have the opportunity to work with a coder, or you've got auditors, so that you're working for a large institution and you have your internal auditors, ask them to do this for you. Or if you're engaging an outside firm or something that's doing your review, have them just do a typical like coding, and then say then, would you just take one of my notes and would you tear it apart and let me know what I'm doing good, and letting me know where I need to maybe improve in some areas. And so I would say I get really good feedback from the providers when we do this. And so it's probably one of the best education tools that you can be provided by anyone. And that is to take your note and then have them go in, and this did not show up real well, but what I will do with my providers is I will go in and I will take this green font, and I will come back in and say, well-written interval history, sets the tone for the visit. Patient seems to be improving with no new issues noted. So of course, if there's other things going on, I'd say well-written note, I can feel, I know what's going on. And so letting them know, great job on that. The exam probably not gonna say too much about that other than you've got your medically appropriate history and exam for this patient. Then I jumped down to my assessment and plan. The coder or the auditor is gonna determine according to the documentation what was monitored and evaluated. So we talked about that on that problems address. So three conditions were listed in the assessment. So we have an assessment and then I've got my plan. So in that assessment, I just had the three conditions. However, according to the plan, there was a total of seven of them, and that's okay. It's okay, you don't have to have them in there. It's my job, my job as a coder or a reviewer to recognize the work that you're doing and it's in the note regardless of where that's located. So on this one, just saying, hey, you've got three in the assessment but you had a total of seven. Just making sure that you're gonna apply all of those to your problems addressed. So you've got the acute CVA, unspecified type or location. And of course, I'm gonna follow up by saying, always document and code to the highest level specificity like you haven't heard that enough. And then we've got our cancer here, unspecified location. Patient had a hemoclectomy, so was it colon? You could only assume, but we don't wanna assume for coding purposes. So we wanna be specific in that. And then you've got the status post code there. So again, I'm gonna be looking at those and giving my physician credit and then awaiting final recommendations there from HEMOC. And so this is gonna be a reportable diagnosis and I would be putting that towards my COPA. Is this gonna probably up my code? And probably not necessarily, but I can certainly wanna consider everything in here. Blood pressure's controlled. I know that's a chronic problem. So it, well, blood pressure's controlled. Now I don't know though, is that hypertension or hypotension? I don't really know, it's from a coding perspective, but we're gonna continue that current regimen. So let's see, continue current regimen will not qualify for RX management if that was the intent because I don't know what the regimen was. Okay, so I don't know what that is. And if I don't see it's prescription, I'm not gonna be able to give credit for prescription drug management. Then continue the pain med there or pain meds. Pain need the location. If neoplasm related, just putting it out there, letting my provider know, hey, by the way, there's specific neoplasm pain codes for that, so giving you that feedback. Increase the Lanta slightly for uncontrolled diabetes. Well, how do you know that's uncontrolled? Was it a lab test that you reviewed? Maybe, because then that might be a data point for some lab in there. So if the lab was reviewed, we would certainly wanna point that out in there and then we've got our orders. So really codes to a level two. We've got our coding grid on the next side and this is what that ends up looking like. So we've got moderate complexity. So that patient isn't necessarily at goal right now with some of these conditions. So categorizing all of those and I would line them with moderate. I really don't have any data for this visit. And then what do I have? Prescription drug management on some of those other meds. So that's gonna end up coming out to be that level two. So that's what I'm doing. I'm looking at those notes and I'm like, problems addressed, data, risk, problems addressed, data, risk, and trying to take each one of those and put them into these categories as the AMA is laid out. So just kind of back summary here, clearly describe the plan, each problem addressed, prescription drug management, make sure that you've got that efficacy in there or there's some kind of an action with it. It's just not sitting there like a comet that the patient's on something. Data points that get overlooked, independent historians, discussions with others, personal interpretations, summarizing those outside records. Make sure the plan communicates the work or the orders that you did on the day of service and then document time precisely, please. Demonstrate time spent in separately billable services are separate, okay? So again, this is a lot of information in a short amount of time. So the go-tos for you are AAPNR here to work for you and advocate for you. And then also, I said, look at the AMA's guidelines out there. I know it's a total snooze, I get it, but I'm in there all the time reading. I'm going to, you know, listening to every Medicare administrative contractor out about this topic. I was in on the AMA symposium this week, little help, very little help. I was very disappointed in that because I'm sure they said, well, we talked about that last year. I'm like, yeah, but we've implemented this and we're on month 11 and we now have questions. You guys should have been addressing these. So anyway, I'm out there trying to do everything I can. And so if there's anything that would be different than what I presented today, I'll be sure and let them know and then they can get that information back out to you. So we do have a few minutes for questions and answers. I'm suspecting there's going to be a few of them out there. And then we are recording this. So if you wouldn't mind coming up to the microphone and if not, then, you know, I'll have to repeat the questions. Got my physicians up here. Can I sit down? You can just, right? You can take it. No, fire away. It'll be, it'll, yeah. I'm Andy Morpurgo from Ithaca, New York. My question is, I know a couple of docs who act as their own coder. At the bottom of the note, they say, today's visit required a moderate degree of medical complexity. Does that help you in any way? No, no, I mean, it really doesn't because, you know, I'm still going to go out like your auditor or whatever is going to go back in and say, I appreciate your input on that, but let's go back to problems addressed, data and risk. So it's going to have to be there. Yeah, it's, yeah, that's not a safety net. If you think it's a safety net, it's not a safety net, yeah. So I was going to ask the way, the difference between like a regular inpatient side versus us is when something goes really bad, we have to transfer them out to a different level of care. So when you see somebody, you do your regular E and M evaluation, and then you go to clinic, you get called, they're crashing in some way or another, and then you have to transfer them. You, it's a, it would be a discharge billing code. And so my, like I'm putting in my own codes and everything else. So I see somebody, I put in my nine, nine, whatever, my level two, and then I spend another hour core to any care, transferring them to a tertiary center, doing all this other stuff. And in the end, my understanding is it's just the regular greater than 30 minute discharge is what I can bill. Cause you can't do both codes on the same day, correct? Is there any way to capture that work at all? Because you can't put an extra time on a discharge code. And so that was where I was just, is there anything I was missing? So. I can just say, we have that happen a lot. That's a real common frustration. I think, you know, you're stuck with your discharge code. Yeah, okay. Unless I guess if you admit and discharge on the same day, there are separate codes. Yeah, there are. But that shouldn't happen too often. Yeah, rehab ops, that's one thing. Yeah, I'm just sitting here and thinking through this. I'm like, oh my goodness. Yeah, we just did. Suppose you get called back in to see a patient, and you've written your note in the morning, you get called back in the afternoon, you don't transfer that. Do you up-code because you've written two different notes? Do you up-code because you've added addendum to your morning note? Like, how does that work? Yeah, well we won't bring the code up unless we now can move over to time-based. So now maybe you're, you know, so now you're thinking, well gosh, I spent 35 minutes with this patient this morning, but now, you know, later in the day, I've spent an additional 25. Go ahead and add everything up for that day. So that's one way of doing it. Now, maybe this morning, everything seemed fine. You know, Mildred seemed perfectly fine. No new complaints, whatever it may be. But now you're called back later in the afternoon because something has cropped up. So now your code might go higher because for today, everything you did today, your problems addressed might go up. It might change your data. It might change your treatment plan. So yeah, so everything that took place that day, even if it's not, if it's two separate encounters on the same day, put it all together. And then that's gonna determine your code. We have time for one more question. Chris Spiewak from Minneapolis. We can stay afterwards too, but for the session purposes, we'll finish here. Yeah. The question I have is that on any given day, the main purpose of me being there to see patients is to look at people's functional deficits and think about how the medical problems are impacting and whether they are making goals towards their functional deficits. So in the documentation, as I'm documenting the impaired mobility, you know, and how we're making gains, is that a goal that I'm working towards? And does that count as a problem in the AMA guidelines? You know, you listed COPD as a problem, we're not at goal. Can I say impaired mobility and we're working towards that goal? Does that count? That's what I'm doing with it, yes, I am. I'm treating those as your conditions and are they a goal or not a goal? Yeah, so I'm treating those as separate. Just as a tip, in those cases that are less medically complex, but very rehab complex, I may specify how their impaired mobility puts them at risk for like injurious falls and other problems, just to make it more obvious that there's some complexity there. Let's all thank our Dr. Shapiro and Linda for their wonderful presentation. They may have some time out in the hallway here. People have additional questions along the way, but we need to change the room over for the next session. But thank you so much. Yeah, I will. I will stay around for a little bit. Thank you.

Linda Duckworth

inpatient E&M coding guidelines

accurate coding practices

medical decision-making

eliminating unnecessary details

detailed assessments and plans

risk associated with management decisions

documenting discussions and consultations

challenges in coding and documenting

patient complexity

thorough and accurate documentation