Hello, and welcome to our session on Mastering Outpatient Coding for 2022. My name is Matthew Grierson. I'm currently the chair of the Reimbursement and Policy Review Committee, and I've got another committee member with us today, Dr. Carlo Malani, as well as Linda Duckworth, who are going to go through a presentation today about outpatient coding for 2022. Here are disclosures, none relevant to the content of this presentation. Our agenda today is very riveting. We're going to be going through several issues that are all very important for billing and coding for physiatrists. And there are many new things coming around the corner, also things to be aware of in terms of telehealth and some updates regarding E&M. And so we're going to first go over an update and review of the CPT and RUC process, learning about how codes are made, how they're valued. Then we're going to transition to discussion about coding for telehealth encounters. And then I'm going to go over some updates for some new codes that are coming through the pipeline for 2022. And then we're going to discuss revisiting the new E&M coding guidelines. We'll talk about how to get some questions and answers to some items that may be lingering at the end of this presentation. So I'm going to turn the time now to Dr. Malani here to go over a review of the CPT and RUC process. Thanks so much, Dr. Grusin. So I'm going to go through an introduction of the CPT and RUC process. Remember that CPT stands for Current Procedural Terminology and RUC stands for Relative Value Update Committee. So CPT refers to the code set that's updated, or I should say that's created and maintained by the American Medical Association. And the RUC is a relative value update committee that values the CPT code set and makes recommendations to CMS about the values. So let's go through it. First, a CPT application is submitted for a particular code or family of codes. A panel from the CPT reviews applications. The families survey the codes for times and values. The RUC reviews the values, times, and practice expense, all of which go into recommendations for valuing the codes. Those value recommendations are then sent to CMS and CMS comes up with their own finalized recommendations and then the codes are published in the AMA or American Medical Association CPT codebook. Next slide. That process typically takes about two to three years from start to finish when a code is created to when it's valued to when it's available for use. So the CPT application process. Applications can be submitted by industry, specialty societies, independent physicians and institutions, or some combination thereof. Applications are reviewed by specialty societies who may submit comments prior to each CPT meeting. CPT panel members, excuse me, CPT panel member reviewers are also assigned to each application to review them closely. And then the CPT panel discusses each proposal at their meetings throughout the year, of which there are three, and we'll discuss briefly later. The code language can be adjusted to follow CPT standards. And then once the codes are approved at the CPT, they're directed to the RUC for value recommendations. The CPT panel member reviewers are appointed by the American Medical Association Board of Trustees. So next, the RUC review process. So new codes are valued and modified and may be revalued by the RUC. Again, remember, it's the Relative Value Update Committee. And that means the job there is to value each code relative to other codes in the expansive CPT code set. So the RUC reviews and re-reviews codes for a range of reasons, which can include increases in volume of utilization, new technology, and others. So the recommendations made by the RUC, excuse me, the recommendations made by the RUC require valuation from the specialties. So to do that, the specialties conduct a random sample of surveys, excuse me, they conduct a random sample, conduct a survey of a random sample of their members. The survey asks physicians to recommend values and times for each code based on comparison to other codes. So this creates the relative value of the recommendations. Survey data is presented to the RUC, which reviews and approves the value recommendations. And then those recommendations again are sent to CMS on an annual basis to inform the values finalized in the physician fee schedule put forth by CMS. Next slide. So the voting bodies. So again, the CPT panel is made up of many different members. It's comprised of physician representatives, as well as coders and insurance representatives. The RUC is comprised of physicians, qualified healthcare professionals who are represented in, sorry, qualified healthcare professionals who are representatives primarily from the American Board of Medical Specialties. Next slide. How does the academy, the AAPMNR, participate in this process? So the AAPMNR prioritizes participation in the CPT and RUC processes as a means of advocating for correct coding and valuation of the services we provide as PMNR physicians. So for both processes, we have advisors and alternate advisors who attend meetings, develop and present PMNR recommendations, review and comment on recommendations from other societies. Our advisors are the advocates. This is where we get to raise our voices in this process of creating the codes or valuing the codes that we use for our work every day. Next slide. So who are our CPT advisors? Dr. Annie Purcell and Scott Horn are our advisors to CPT. They attend three meetings per year in February, May, and September. They help develop PMNR code applications and they review and comment on applications relevant to PMNR. Who are our RUC advisors? That includes myself and Dr. David Reese. We attend three meetings per year in January, April, and October. We review coded surveys from our members and make value recommendations based on the survey information and data. We present those recommendations at the RUC meetings three times a year. Next slide. Some of the big news out of early 2021 was the earning of a permanent seat on the RUC or the relative value update committee. In January, the RUC voted to create a new permanent seat for physical medicine and rehabilitation. This was a big feat. Prior to this, we only had the ability Prior to this, we only had the ability to have rotating representation on the RUC and now we're there permanently. This was a process that took many years culminating in the final seat and it was a true team effort, but there were some key players. Dr. Matthew Grierson, our advisor Carolyn Millett, and Dr. Annie Purcell were some of the key players in making sure that we were able to secure the RUC seat ultimately. Currently, Dr. Matthew Grierson is serving as PMNR's RUC member with Dr. Clarice Sin as the alternate. The role on the RUC for PMNR is to offer our expertise in RUC deliberations, but not to specifically advocate for our specialty. That's the role of the advisors. Next slide. All right, now I'm going to turn it over to Linda Duckworth to talk more about coding for telehealth encounters. Thank you so much. We can go to the next slide there. Okay. I think one of the key takeaways for everyone from this part of our session this evening is going to be that this is just continually moving, continually changing. I really want to focus a little bit more on Medicare and during the pandemic because we've seen so many changes over the last year, year and a half now. That's where I want to put most of our efforts in this short amount of time that we have. Telehealth has grown exponentially and we can probably spend a couple of hours on it, but I know that nobody wants to do that with their time. We just want to hit the critical points of this. I don't think it's necessarily the physician's role to be trying to stay up on top of all of these changes. I think that this is where you really want to find that champion partner, coder or someone in your billing office that is going to be keeping their finger on the pulse of this with all of your payers. Not just your Medicare, but what is Medicaid in your area doing? What about all your commercial plans that you're contracting with? Because they all have their own different take on what they're going to allow for telehealth during the PHE and what they're not going to allow. That's what you need to do is connect with those people there. Another really great resource I want to point out, and I think a lot of people are not aware of this because it's not necessarily driven by Medicare or Medicaid, but if you'll go to the Center for Connected Health Policies, that website there that we've got in the middle, it tells you actually about each state's regulations in relation to telehealth. It does touch a little bit on Medicaid, a little bit on a Medicare. There's nothing in there about your commercial plans, but at least it talks about some of the other regulations outside of the insurance industry on what your state regulations might be, and even for visits that might cross a state line. I think that that's an excellent resource out there for you all, so make sure that your coders or your billing team are aware of that additional resource there. They track the telehealth laws, regulations across three different categories, 19 different unique topics that they cover and go into play, and it's a very easy to navigate website, so check that out or at least have your team check that out. You can look everything up by state, and so it's pretty easy to navigate. Next slide, please. Technology here, so really what we have to understand is there's so many different types now of remote patient monitoring, interacting with patients, you know, using computers and all of these different ways that we can communicate with our patients, but when we're talking about traditional telehealth, we have to make sure that we are using live, interactive, audio, visual, visual, and you're going to want to document that in the medical record, and so you want to get yourself in the habit of really starting your note by saying, this visit is being completed via telehealth using whatever platform that may be, and we'll talk a little bit more about some additional language you want, but really that's the best thing to do is start your note that way. When I'm doing an audit, I'm looking over here maybe at the claim, I'm looking at the charges, typically an E&M code, looking at those charges, seeing that we're using modifiers or locations that indicate it's telehealth, then I go over here to the note, there's nothing being said about telehealth at all in the note, so I'm trying to figure out, was it telehealth, and you just didn't document it, or was the claim incorrect in the way that they reported that, so we have to make sure that we're documenting that, so that real-time interactive audio-visual is a must. It's your hard stop. If you're not doing that, then you're not going to meet the whole qualifications of that telehealth there. The Office for Civil Rights is going to have a little bit of leniency through this PHE when it comes to HIPAA, kind of relaxing a little bit on what type of devices or platforms that you can be using, but again, you have to stay on top of this. You've got to stay on top of this, so if they kind of dial it back in and start to restrict on what kind of platforms, you're going to want to be aware of that, especially if you have any kind of an incident, any kind of a privacy or security incident, you want to stay on top of those kinds of things, so they had even came up and said that FaceTime and even Skype were going to be acceptable, and I would think that'd be certainly true, like a year ago when everybody was almost afraid to leave their home, that's really when that came about. Technology cannot be public-facing. I think we all know that. That's kind of a no-brainer given there on that one. Next slide. So, the locations during the PHE, we've kind of broadened those a little bit, and you can see there's a number of these here. Skilled nursing has been there before, but we've actually expanded those services. They've expanded into the inpatient setting, so that might be applicable for some of you. Physician offices, we've kind of loosened that a little bit there too, and I think that that's a great opportunity. I myself have had a couple of telehealth visits in the last year. I love it, you know, 20 minutes out of my day versus an hour and a half of driving to and from, so I'm a big proponent of keeping this telehealth on a roll here, but these are the locations that we have out there, at least for Medicare right now. Next slide. So, expanded services, and this is what I was saying here just a moment ago, so when we're talking about Medicare. So, there's an expansion of those services, and you can see that it was last updated here, August of 21, provides the code status, so you can actually go in and look by CPT code what is allowed for telehealth, and so you can find that, and whatever you're wanting to do, you know, it's everything from psych to inpatient to outpatient, whatever, you can go look it up by code there. So, you can see here again a long list of different services that are going to be available, and the things that they've expanded now are the initial visits. So, when we were talking about the outpatient in a facility type setting, or in the initial inpatient setting, or the nursing, you know, which all applies to all of you, they've actually added the initial visits as well as discharge now. It used to be the subsequent, we're sitting in there, but now that they've expanded that for us and allowed us to do those other services, they even threw critical care in there. So, you can tell that there's a really nice variety of different services now with this expansion, at least during the PHE. So, next slide. Common E&M services kind of covered this all a little bit already. I wanted to point out, though, in that SNF setting, the nursing home setting, with this expansion, they also now have reduced the number of visits or the time in between your visits when it came to telehealth. We used to be allowed to do one every, pardon me, every 30 days, and they've brought that down now to every 14 days. And what I'm talking about is the medically necessary services, because we all know that in that setting, you know, there is some limitations on how frequent we can see these patients. So, as long as the medical necessity has been met according to our LCDs and all of that, at least we can do telehealth now 14 days versus 30. So, you want to advance that. And I think that that's actually on a permanent basis, not just the PHE, but we'll want to maybe double check those facts there, but I'm pretty sure it's on a permanent basis. So, when we're talking about what do we need to be documenting, we said we really need to start the note by saying this is a telehealth visit. Great idea to say even maybe, you know, audiovisual communications were intact for the entirety of the visit, or if maybe you lost a little bit of, you know, visual, you could even comment towards the end about that, but not a bad idea. You know, shake it up a little bit, make it patient-specific, got to love those patient-specific comments. But you want to document the consent. Okay, so consent has to be, you know, you explained to the patients what their rights are, you know, the privacy, the security, and all of that doesn't have to be, you know, six pages long diatribe of what all's involved in this, but you do need to briefly explain that or at least have your staff do that as an introduction as they're kind of getting that patient queued up and ready for you. So, good idea to start that out that the patient, you know, that their consent has been obtained and all of that. So, you want to kind of include that. So, if you can even build a template, that is going to take care of a lot of that for you. Just make sure that that template is an accurate representation, though, of really what took place during that visit. We don't want to just be pushing that button and just going blah, blah, blah, blah, blah, blah with a bunch of stuff we didn't do. So, make sure it's really accurate representation of what took place. The type of technology used, you also want to name that as well. So, and again, if you have any hiccups in there, go ahead and document it, make them patient specific. Next slide. So, coding challenges. You know, when we're talking about the office setting, so with our 2021 documentation guidelines where we don't necessarily have to have that history of the exam anymore, telehealth is a little bit easier, those codes to achieve because I don't have to worry about an exam. Now, if we're talking about the other locations, so our coding is still under the 95 and the 97 guidelines where you have to have that exam, how are you going to do that? How will you do that in telehealth? That's going to be difficult for you with those initial type visits where you have to have the history and the exam and the decision making all come together for code selection, right? We have to have all three key components still in those arenas. Now, there's nothing out there that I've ever seen that is allowing any kind of, you know, we're going to forgive the exam, there's going to be a leniency, you know, there's really nothing out there that at least that is published. So, I think one of our fixes maybe for that, if you find yourself seeing patients in the initial setting, and that might even be a consultation, whatever that may be, something we might want to consider then is document or, excuse me, coding these as a subsequent visit. Medicare has always told us that if our history or our exam falls short of what we need, which would be detailed in these settings, that you can go ahead and code them as subsequent. So, that is an option that you want to discuss with your billing team or with your coders and make sure that everybody's understanding of that. Otherwise, it might be difficult for you to get a detailed exam for some of these visits. So, it's an option. Next slide, please. Report the place of service when we're talking about telehealth. We're going to report that place of service like we would on a traditional claim. So, if it's an inpatient type visit, that's going to be the place of service. And your billers or your coders should know that. That's usually kind of outside of the physician's realm and not maybe something you need to know, but this would be something that you would definitely want to make sure that you're passing along to your coders and your billers there. So, it's really just like if it was a live in-person face-to-face visit is how we would report that. Modifier 95 for Medicare, they need to add that to their claim and they should know that. They should know that. Now, your other payers have different takes on these two topics. So, again, I could just see the billing office have a little matrix out there on their wall that says this is what we do for the Blues and Uniteds and all of that, but this is how Medicare is wanting it done. So, they have to continually be monitoring those communications from those payers to make sure that you're doing it correctly. Next slide. Again, ever-changing, monitor it weekly, Medicare commercial plans. I just can't encourage your staff to stay up on that as much as they possibly can. The other thing, too, is are they going to whittle this back down after the PHE? Everything we hear that they are, they're going to bring it back in. They're going to rein it back in on the location of the patient, what all's going to count, what codes can be done. So, do not let this just sit on a shelf. You're going to have to stay on top of this. CMS is going to review providers that have gross potential overutilization, maybe, and, you know, that's, I don't know how they're really going to identify those people because I know that through the PHE, we have seen just skyrocket the number of of telehealth visits for all specialties. And so how they're going to actually target those, you know, I'm not sure exactly how they're going to do that data analysis, but they're going to do it. And the OIG has already put it on their watch list for the upcoming year. I think it's on the 2022 plan. So that means that they're going to be going back and looking, looking backwards. So it's just important that you're aware of documentation requirements, what those technology requirements are. And I think that those are probably the big critical points for you as you consider your telehealth and continuing telehealth. Or maybe if you haven't started it yet, those are going to be the things that you're going to really want to focus in on. Next slide. Is that it? Oh, here's the resources then. And I really wanted to highlight this for the audience there. The telehealth FAQ. And I got the big star right there by it. So that is going to be wonderful. And look, it was last updated just this month, even. So you know that you're getting really good up to date information with that. But that's probably my go to when I need a quick answer for Medicare on telehealth is that FAQ. So that's something that you really want to go in and explore is that document. And I think the next page is probably another list as well. Just some more resources there for you. And I believe AAPMNR also has a like maybe like a full 60 minute or hour long telehealth educational recording on the website as a member that you should be able to access. And so you might want to take a few minutes and go in and look at that. If you if you're doing telehealth or want to consider doing telehealth. And I think that might be it. Thank you so much, Linda. You're so right. There's so much that changes week by week. It's so important for our us to work with our billing teams to keep on top of that. And thank you, Dr. Malani, for that overview of how codes are made and then how they're valued, because that's going to get us into our next discussion, which is our 2022 updates for procedural coding for AAPMNR. So in terms of procedural coding, there's the AMA CPT code back and that's updated annually, which includes all of the new codes and highlights them. Now, the new code book for this year is available and it does include two very new just hot off the press codes that will be relevant for our academy members. Those are thermal destruction of the interosseous base of a triple nerve. So all of our colleagues in the world of pain medicine are very familiar with this procedure. And so now there is a CPT code where they can start to get paid for this. And then there's the remote therapeutic monitoring code, which is a family of five codes. Four of them are relevant to PMNR. And we'll talk about both of these codes. So the thermal destruction of interosseous at base of vertebral nerve, sometimes known as the intercept procedure. This involves two codes that were developed to really capture this work, which involves a thermal destruction of the base of vertebral nerve to treat chronic low back pain. And really it's used to treat axial discogenic back pain. And so to do the procedure, the vertebral body is accessed where a needle goes in to get to where the nerve is, and then it is heated up using a radiofrequency generator, similar to some of our other radiofrequency ablation procedures. It's typically performed under fluoroscopic guidance. So because of that, that fluoroscopic guidance is bundled into the procedure and not built separately. So here are the two codes. The first is 64628, followed by 64629. And the first code is for the first level, and the second code is for each additional level. So again, you wouldn't report this separately with any imaging. And just recognize that that second code, the 29 code, is an add-on code. And you must have the base code first to be able to report it. So it's not too complicated, not too technical. You just report the one code for the first level and then every other level separately, you can list 64629. All right, so let's move on to this other family, which is a new set of codes for remote therapeutic monitoring. Now, this is a set of codes that many of our members may not necessarily know about, but it is really interesting. It encompasses therapeutic monitoring with the use of procedures to monitor specific non-physiologic parameters related to a treatment underway. So, you know, it's not looking at heart rate. It's not looking at breath rate. It's looking at other things. And some of that could even be a collection through an app, a patient's responses to standardized surveys. Some of it could be the app is actually looking at like some sort of biomechanical analysis. There's a lot of new ways that manufacturers are thinking about this. However, one thing to keep in mind is that these codes must be used only with medical devices that have been approved by the FDA. And so right now, there's not you know, the number is growing in terms of how many of these applications that really are out there. Now, there's a whole other set, a whole other family of codes for remote physiologic monitoring where they are looking at heart rate or even glucose monitoring. This does not replace those. These are a completely separate family of codes. And of course, these services, when you use these codes, must have been ordered by a physician or another qualified health care professional. So going through the family here, the first code is 98975. And so this is for the initial setup and patient education on use of the equipment and for many clinics that will actually be performed after it's ordered by the physician, by some of the staff on site. It's not necessarily a code that has a lot of direct one to one physician time. The next one is 98977. You'll notice I skipped one of the codes, 98976, because that's more for the respiratory system, not the musculoskeletal system. But for 98977, this is actually the device that's supplied by the manufacturer and which then transmits all of the data which can be monitored over the course of 30 days. And so it's billed for each 30 day increment that that device is in use. And just some notes on 98975 and 77, you're not going to report the 98975 more than once per episode. And you can't report that code if you're monitoring for less than 16 days, because it's really thinking about billing in 30 day increments. And you're not going to want to report these actually in conjunction with codes for remote monitoring of more specific physiologic parameters. For those, you would use the other family that I discussed earlier. So in terms of remote therapeutic monitoring treatment management guidelines, these can be performed at the same time that you're doing chronic care management, principal care management, or transitional care management services. But that time must be documented and counted separately. And I know a lot of different systems have different ways of tracking that. And if you're ever audited, you need to be able to be able to separately document, you know, I was doing this during that time. And then I was doing this other activity during another time. That's really important for you to put into your notes in case you're ever audited. But these codes are time-based and then billed on a per month basis. The base code is used for the first 20 minutes of time. And then there are add-on codes that are available to be billed for any additional 20 minute increment. And so both of these codes require at least one interactive encounter with the patient or the caregiver. And that contributes to the total time. But if you're going to bill the code for that 30 days, you must have at least had some contact with the patient or the caregiver to be able to bill for the code. And just as a heads up, if that ends up turning into an E&M visit, you can't double dip. And so, you know, what you're doing is either part of the E&M visit and document is part of the E&M, or it's part of the management code here for the remote monitoring. So if you want to see the complete list of all the codes, which can and cannot be associated with this, I'll refer you to the 2022 CPT codebook. And so here's the base code for the first 20 minutes and then the add-on code for each additional 20 minutes. And this really is the actual physician work where you're analyzing the data, you're looking at all of this information that either is coming to you in an app or whatever form that the manufacturer provides it to you. And you're making medical decisions. And it can be like two minutes here, two minutes there, five minutes here, five minutes there. But you will need to figure out a way of how to account for all of that. And many of the systems out there, hospital systems have ways of doing that. So chat with your billing staff on some of the best practices there if you don't have something already. But just keep in mind that the add-on code 8-1 is an add-on code and can only be built when the 8-0 code is also built. And these are just built once every 30 days. And so that is the end of my section on the report therapeutic monitoring codes. And Linda, I know you're going to chat about some of the revisiting the new E&M coding guidelines. And I think you might have had some advice in terms of some of the experience that you've had over the last little bit in terms of some of the facet codes. Yeah, I was going to chime in on that real quick. Just because I do spend so much of my time anymore helping physicians or groups or practices that are finding themselves at odds with Medicare. So basically meaning they're kind of in trouble. And we've seen a lot of activity with the facets lately. And what we're finding is that getting all that criteria documented, that's in the LCD. And so a lot of our commercial payers with their pre-certification processes, they're asking, is it primarily axial? Has it been there for three months? And have they tried conservative measures and blah, blah, blah, blah, blah. And they'll go through that. And if you mark all the boxes, then they'll go ahead and they'll give you pre-approval or pre-authorized services. Well, Medicare doesn't give us that. I don't know if you want to call it a luxury or if it's maybe more of a curse. But we're kind of finding now that when Medicare is coming in and looking at these charts, that we aren't able to come up with that information. And even just looking at the visit that maybe resulted in the determination for the need for the medial branch blocks, moving on to the facets, and then going on to the ablations and all of that. We're looking not just at this note, but we're looking at a series of notes, my audit team, and we're going back and we're trying. And we're trying to pick through this to see, have they tried? Well, what conservative measures and what is the pain scale? And so we're actually trying to put all that together. And we're seeing a lot of failure in that. And we're finding these physicians are paying back thousands and thousands of dollars because they're not getting all of that. So if I could encourage your practice to create your own internal checklist before you're scheduling these and saying, do we have this? Did all of this take place that meets that LCD criteria? Then we want to feel comfortable and confident when we're doing those procedures. If you're in a position where you have neurosurgery or orthopedics or referring patients to you for these types of procedures, you will rely, you have to rely on what they're putting in their medical record. So if you're audited, you're going to have to go back and get all of their medical records to support that medical necessity and meet the LCD. You're going to rely on them. So if you have a, you know, a group or a particular physician that is, you know, really sending a lot your way, I kind of, you know, would encourage you to do like a little self-check, self-audit on that and see, can you go back and recreate all that criteria? If you find yourself in an audit, because it's way more difficult than what you might think. And so that is my little takeaway on today on, you know, documentation tips as far as the procedures go. So, and I said, we're finding a lot of groups are in a world of hurt over this because we just, we can't get the information that we need. And, you know, and so if you end up in, you know, your Medicare is coming after you and then they want another round of charts because you didn't do so good. And then if by chance you would get any kind of notification from what they call the UPIC, U-P-I-C, Unified Program Integrity Contractor, I think is what it is. If you get something like that, then you probably do need to reach out. If I can give you some advice, reach out to maybe your council on something like that before you take it upon yourself, because that those can go down south very quickly. So you want to get some advice from somebody that's worked in with those types of projects, whether council or, you know, consultant or something like that. But you probably going to need some help if you get something from the UPIC. And we're seeing a lot of that lately. So anyway. Thank you so much for all that information. One thing I will say is I've seen some physician practices, you know, really start to integrate what you're saying as part of, and they begin it through a project, like a practice improvement project that a lot of us have to do to maintain our certification. So this is, you know, just one idea of how to implement that in your practice. But thank you for that great information. Yeah. Self-evaluate or self-audit, whatever you want to call it, or outsource or whatever you need to do. But that is really it's such an investment in the well-being of your billing program. It really is to get independent feedback on what you're doing. So let's go to let's go on to our next topic and our next slide. Oh, you know, here we go. OK, so so everybody's up to up to speed on this. Know everything about it. I kind of doubt that, you know, to me, I was thinking, be careful what you ask for, because we wanted those old guidelines to go away so bad. So AMA came in and replaced them. And there's there's still some pitfalls in there. You know, I just don't know if you can ever find a perfect way of doing this. I know everybody's super excited about the history and the exam being removed from the equation, right? Well, I am in the fact that because I think that under the 95 and 97 guidelines, what they were wanting you to do on your more complex services at sometimes was a little bit ridiculous. And you know what I'm talking about, the review of systems and, you know, family history and things like that when it really wasn't relevant to the visit. So, you know, we have to be so thankful that that went away. And remember, I'm talking about office visits right now. We're not talking about anything inpatient or rehab or whatever. We're just talking about our office visits right now, getting our feet wet with this code family before this. I think it's going to you're going to be seeing this transition over in 23 to all other areas of E&M. So even if you're not doing office right now, if by chance, you know, you're more in the SNF setting, you still need to pay attention to this because it's going to apply to you here in about another year. And you need to be ready for this when it happens. So, you know, we don't have to do deal with the history anymore as far as the review systems and past family medical and social histories. That's great. That's great. We don't have to worry about getting an extensive exam when it's not necessary on a lot of our visits. But the one thing that I do want to put out there, and if you've ever heard me speak at AAP Menard before, I'm a huge proponent of a well-written history. It sets the tone for the visit. And especially if you're talking about someone that's non-clinical reading your note, it helps tremendously. And so don't don't overlook the importance of that. And, you know, I've told coders when I've taught coding in the past, I've even told them, you know, like critical care is time based. I'll say, if you not picked up a note before and started reading it and thinking, oh, my gosh, this is horrible. I wonder if it's critical care. And then they scoot to the bottom and like, sure enough, there it is. So what I'm saying is, you know, we can pick up a note and start reading and know, you know, sometimes if it's going to be more complex or if it seems to be a little bit more straightforward. So it really does give a good feel for that visit. So whether it's your HPI or your interval history, I don't want you to overlook the importance of that. OK, big tip from me. Big tip, because, again, if you're in an audit situation, whether, you know, I'm just doing a routine audit for somebody or if we're doing the appeal work, we're going to pull the previous note. If we if we can't get real good clarity on what's going on today, go look at the previous note and start doing comparisons. Well, this has to be a new problem because it wasn't at the last visit or it wasn't in their history or oh, you can see it's worsening because if you compare to the last note, you know, so we find ourselves doing that. So if you can really start those notes out with a really well written HPI or interval history, it really will help you in the long run. And it's clinically relevant to you. It's not just fluff or coding. It's it's clinically relevant for you to be doing those. So and like I said, speaks to the severity of the problem and all of that needs to describe. OK, so this is so important, whether you're going to be describing in the history or possibly in your assessment, you absolutely have got to be taking these conditions that you're seeing and categorizing them acute versus chronic. And we're going to take a look at that when we get into the decision making tables. I'm going to show you why, because that's a decision that these coders have to make. So let's just say if you go out there and say the patient has back pain. Is that acute? Is it chronic? How long has it been going on? Or I don't know. I don't know. So I don't know where to go with that. I don't know which direction to go with that. So having something in that history to bring that information in or possibly bring it forward. And we're going to talk about bring forward information to but if it's brought forward, at least I can see, oh, patients had back pain for eight years. It's chronic. So we're going to be good on that. But we really have to know what is chronic and what's acute. That is probably our biggest audit stumbling block on my team right now. Can't figure it out. Cannot figure it out without going backwards and looking at other records sometimes. Then if you've got that chronic condition, you're going to need to explain the status of that chronic condition. Now, again, is it going to be in your assessment? Is it going to be up here in your HPI or your interval history? So we want to be using these words. We want to be using really good descriptive words. It's improved. It's stable. It's at goal. It's unstable. Failing to respond to treatment. It's worsening. Anything like that. So if your patient's coming back in with flare ups or whatever it may be, use those descriptive words because it really impacts the decision making. So since now we don't have to we don't take into account the level of history or the exam, we're really looking at this decision making component. Then those descriptive terms are huge in getting you to the right code at the end of the visit or next visit. Next slide, please. OK, so the decision making. So we had our three key components, the history, the exam, the decision making. So now we're down to the decision making. But we still have three components to this. So it's going to be the number and the complexity of the problems that were addressed. Addressed at the time of the encounter. Amount and or complexity of data to be reviewed and analyzed. And then the risks or complications or morbidity or mortality of the patient from your management options. Next slide. Chronic and stable. So AMA in all of their explanations, I even went ahead and bought into their to their compendium. Love it. Love it. They've got all kinds of really nice, good, their definitions of terms that are now being used as they see it as it relates to E&M coding. So chronic is that problem with the expected duration of at least a year. A lot of physicians will even say, well, once you hit like a three month mark, I'm going to consider that to be chronic. So maybe that's going to be a personal interpretation too. So there's a little bit back and forth on when that actually becomes chronic. But we certainly know that if I pull up a note and I can see the patient wrenched their back last week, I'm not going to go to chronic with something like that at this point. So that's a little bit open to interpretation, I think. But this is what the AMA had to say about that. And then stable. So they're using the word stable on our E&M coding. So for the purposes of that, defined by specific treatment goals, a patient who is not at their treatment goal is not stable. So, that might be something you're wanting to think, how do I work that language into my note so that whoever is going to be auditing my note or is a coder going to be trying to interpret my note, you know, I kind of need to relate to those people, to those readers If my patient is at goal or not at goal, because so many of these patients, we're never going to get them walking again or 100% pain relief or whatever that may be, but maybe our goal is to get those ADLs up there to where they can sit through a chirp service and not have to get up and move around or whatever that may be, you know, so you're going to be setting those goals with your patients. And then, as you're seeing those patients and in those follow-up visits, you want to convey where are they at in relation to that goal. Because if they're doing good or they're stable, you know, we're going to certainly be looking probably at a lower level of code, that makes sense, but if these patients are worsening, they're not at goal, it's these exacerbations or whatever they may be, you're using those descriptive words, which leans me now more towards probably a little bit of a higher code. So, you have to get yourself in the habit of using those really good descriptive terms to convey what's going on with that patient. Next slide, please. Problems addressed categorized. Okay, so this is what it looks like as far as the type of conditions. Self-limited or minor problems. In this, with this audience that we have here tonight, it would be a rare occasion that we would be dealing with something like this, okay? So, we have to remember that this is all specialties, so this might come into play in family practice, might even come into play in the ER, but in this audience, I don't see this happening. I'm not saying it never will happen, don't ever say never, but it would be a rare circumstance. So then we go into our chronic stable condition, and that aligns with low. And what is a low code, for example? A 213, 99213. Maybe it's an acute, uncomplicated illness or injury. That would be your lows. Then you're going to take it up a notch. Chronic illness with exacerbation, progression, or side effects. Those are going to be moderate problems addressed. And so now you're going to be up there with like your level fours. So that's why I'm saying that your word choice is so important when you're documenting. You want to be accurate, and you certainly want to be truthful, but you want to be using these terms when this is what's going on with those patients. The undiagnosed new problem with an uncertain prognosis, maybe that would come into play with maybe some more of your severe cases. Acute illness, systemic symptoms, acute complicated injuries, again, those are going to be those moderate complexity, those are going to be those level fours, and then you've got your highs there. So severe exacerbations, those should be the worst of the worst patients that you see. Because we're thinking about this on a scale, our coding is a scale. So you've got your straightforwards down here, which are the most simplest of cases that you ever did see. And then, of course, you've got your highs, which are going to be the worst of the cases that you're seeing. And so we want to see that fluctuation as you would with your patient population. Next slide, please. Problems addressed, categorized. Okay. So this is kind of back to that slide I kind of talked about earlier where I was saying that we have to make sure that we can differentiate between an acute and a chronic condition. And if it's acute, remember I was telling you, is it low because it's uncomplicated or is it moderate because it's complicated? So I have to be able, as a coder or an auditor, I have to be able to try to determine that from your note. And then the chronics, if it's chronics, is it stable or is it unstable? And again, it's going to be your word choice what that's going to come down to. Next slide. So the number of conditions, again, we're looking at the number of conditions that you're addressing, that you're managing today. So not necessarily everything that we put in the assessment because sometimes we see, oh, there's the diabetes and, oh, there's the hypertension. So we'll see some of those other conditions being put in there. But the coder or the auditor is going to be in there looking maybe back at your history or your exam or the plan and trying to determine, did you really address this? Did you really manage it today? So they're going to try to abstract that information from your note. And so the AMA even says then, too, this is important, symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. So if your patient comes in today, and I hope I explained this correctly here and maybe one of my physicians could correct me if I'm wrong, but if they came in and they're saying, well, I've got this neck pain and then I've got pain down my arm and then down into my hand or something like this, I mean, do I have finger pain and hand pain and arm pain and neck pain, and now I've got four things I'm addressing? Probably not. So that's that cluster of symptoms kind of leaning you towards in one direction. So we have to be a little careful in that as coders or physicians selecting this or even the auditing. So this is a nice little slide that they've talked about as far as the number of conditions. And then other things you want to see in here, let's see, what is it? The final diagnosis condition does not of itself determine the complexity or risk. Extensive evaluation may be required to reach the conclusion. The signs or symptoms do not represent highly morbid. Another thing too, therefore presenting symptoms that are not likely to represent highly morbid condition may drive the decision making even when the ultimate diagnosis is not highly morbid. So that presenting problem is really frightening and we're thinking, oh, it's this, but it ends up not being that. Sometimes your codes can still stay at a high level is kind of what they're saying there. And then the evaluation of treatment should be consistent with likely nature of the condition. OK, so let's go to the next slide here. Data. Everybody got pretty worked up about the data because the data has kind of been expanded a little bit here. It includes medical records, tests, other information that you got to obtain that's ordered, reviewed and analyzed for each encounter. So the data is out there. Something we want to think about is a unique test. So when you hear someone say a unique test, you get a data point for each unique test. Well, that's that's really defined by CPT. So if it has a C individual CPT code, it's an individual unique test. And so what they're telling you, like a CMP there that has one CPT code, even though it's 14 different tests, but it's one CPT code. So they're just going to give you one data point for that because it's one CPT code. Credit cannot be given to a test at the time of the order and then for reviewing later on. So you want to maybe come up with a good system within your practice that when you're counting your data points, I would advise you to go ahead and do them when at the time you order. Then when you have the patient come back and then you go back in and look at, I don't know, the urine drug screen or whatever it may be, you know, an X-ray. If you already did your data points at that first visit or the visit before, you can't now count those data points on your subsequent visit because you already did the order and you got paid for the order. So that test only gets, you only get credit one time at the order or at the review. And I think for consistency, I would always go with the order. That's really what I would recommend that you do. Next slide. So I wanted to point out on this one here too that you've got straightforward, you know, your lowest of level of visits, you don't have to have any data points. Low level would be like your 213s or 203s must meet the requirements of at least one of the two categories. So category one, test and documents, any combination of the two from the following, and it bullet points it out there, external notes, each unique test, ordering each unique test. So you can get those data points start to accumulate. So category one or your category two would be requiring an independent historian. I want you to be a little careful with this. If you do, if you're in that position where you have to have a conversation with nursing home staff, you're in the office, but you're having to have a conversation with nursing home staff or a caregiver or a, um, the child of an, of an advanced age patient who is a poor historian and cannot relay that history themselves. You're going to the extra effort to go get that information. That's what this is talking about. This doesn't mean just because the wife is sitting here next to her husband and she's chiming in and saying, no, honey, I think it's, it's, it's every two days that happens that that's just them contributing to it. But this is really physician work to go and get that information. So be a little careful in the way that you word that. I've seen some of the coders being overly aggressive and trying to give data points for something more like a, you know, just chiming in on something next, uh, next slide there. And so then on your moderate have to have at least one of the three of the three categories. So there's your category one, and it talks about the test. And again, are you getting external notes from a unique source? What that means is you're looking at notes from outside your organization. So it can't be your partner's notes. This is outside of your group and your specialty. That's what you're doing here. And then you're back to your unique test or ordering. And then the historian still comes into play at moderate. So you can see the bullet points are still kind of there. And then I wanted to point out on the category two, this is so important for you all for this audience is that an independent interpretation of a test. So if you're looking at images or EMGs or whatever that may be, and you're coming up with your own personal interpretation, you want to word it that way. So you get more weight for doing your interpretation on your own versus simply reading a report from someone else. So get your language in there in your note correctly. That again, relays that to the reader that says, this is my personal interpretation of this. Now what's important though, is that you're only getting that data point for something you didn't build for. So if you did the interpretation for the imaging, for the x-ray or whatever it may be, you don't get to come over here and do your data for your EM. So that's kind of that whole double dip concept. So make sure you're not doing that. But if you have the patient bring something in from an outside organization and you've got some type of a CD or something that you're looking at, then you just want to make sure that you clearly state that in your note. And then also you can have discussion management or test interpretations with other providers. So if you're having those conversations, document those conversations. All of that starts to add up and it really speaks to the complexity and the amount of work that you're doing. Next slide. Now we just start to graduate more and more. You can see here, and if we're talking about those high level visits, so these would be like our level five visits. And again, you've got your two of the three categories. So you're going to have to meet the requirements from category one that we talked about. Category two, we already talked about. Category three, we've already talked about. It's just that you have to have more of those to align with those higher, more complex visits. Next slide, please. Now the risk. We really want to be careful that we're documenting patient specific risks. Talk about that here in just a minute. And then we may redefine what attributes to risk. So it's not so much the presenting problem anymore, but it's really more of the management options, okay? So what kind of tests are we doing? What medications are we going to order? What therapeutic measures are we going to be doing? That's really where this risk is going to drive. Now where we're saying, document your patient specifics, we know that there are risks with a lot of procedures that we're doing. It's just a given. But what you want to do, if you've got a low risk, maybe it's just a TPI that you feel like kind of a low risk procedure for that area that you're treating, but maybe there's something in the patient's medical history that would increase that a little bit. I don't know what that's going to be. Possibly I don't know if they're on blood thinners or whatever that may be. But if it's something patient specific that would increase their risk, you certainly want to document that. Okay, so patient specific, because it's really important that you document that. AMA says definitions of risk are based on the usual behavior and thought processes of the provider in the same specialty. Therefore events that are extremely improbable, such as having an allergic reaction to any antibiotic, would not be counted. I wish they had that out there for many years in my past audit experience. I really could have used that backup many times. For the purposes of decision making, the level of risk is based on consequences of the problems addressed at the encounter when appropriately treated. Risk also includes decision making related to the need to initiate or forgo further testing. So we want to make sure that if you recommend medications or testing or whatever that may be and then the patient says, oh, I don't think I want to do that, you document that. You're still going to get credit for that work that took place. There's still work involved in that. And sometimes, I think sometimes even more, because then you're going back and covering your tracks. I strongly recommended the patient did this and then they didn't want to do it. So sometimes those can even be trickier visits. So you want to document that. Next slide, please. The risk. Then you can see here, straightforward, the minimal risk, low is going to be your low risk of morbidity. So your straightforwards are going to be those most simplest ever visits and probably going to be like your level twos. And then your low is going to be those level threes, low risk of morbidity from additional diagnostic testing or treatment. And then you jump up to the moderate category. Everybody's a fan of those moderate categories, because that's where we're our 214s, 204s are going to lie. So you want to pay close attention to this, and that's where your prescription drug management comes into play. But I want to caution you, prescription drug management, it does not in itself make a 99214. So that's kind of an urban legend. It's more to it than just writing a prescription to get to that level four. So we want to be careful on that. Everybody seems to just really take that and grab it and want to run with it, but we have to be careful on that. So decision regarding minor surgery with identified patient or risk factors. So if you've got risks associated with those facets or epidurals or whatever it may be doing, knee injections, whatever, you know, and there's something patient specific, make sure that you're documenting that. Decision regarding elective major surgery without identified patient specifics. That's where this would fall. And then diagnose or treatment significantly limited by social determinants. So if that comes into play. Next one. And then your high level. You can see your high levels here. And so AMA even wrote up their definition of that intensive monitoring for toxicity. And I got to tell you, those are pretty nasty, scary drugs. Not so much in this specialty, I don't think, as far as what I've encountered in my years working with you all. And then, of course, elective surgery with those patient risk factors, emergency major surgery regarding hospitalization. So those are kind of those high risk patients, those level fives. Let's go to the next slide so I can kind of show you how this kind of works out. So the two of the three following the complexity of the diagnosis is low. No data, even though the risk is moderate. Patient seen for chronic pain management. So I think if you click the advanced, the next slide, if you, yeah, there you go. I was thinking I was going to be doing this myself. So I'm so sorry. I'm going to put you through this. So as you can see here, if the patient was seen for a chronic stable pain management, so they came in for the refills, right? So they came in for their refill today, they're stable, they're at goal. So this is going to be a typical 99213. So my number of diagnoses is going to be fairly limited, and it's going to be low for one stable chronic. I don't even have to have any day to day because we're doing the two out of the three on this. New patients, established patients, it's a two out of the three thing. So low, no data, but I have to write that prescription. So I'm going to write that prescription. And that's going to be a moderate risk for the kinds of drugs that we deal with typically in this specialty. But what does my code end up being? It ends up being low. Two of those three, the complexity, the data, and the risk come out to be the low, and that would be a typical 203 or typical 213. Go to your next slide, and we're going to do the same thing here. So now if we want to jump up to a 204 or 214, the number and types of diagnosis are moderate and the data is moderate, but my risks are low. So if we go here, we have an acute problem or an exacerbation of a chronic. So that's where that exacerbation of that chronic bumps it up a little bit because you clearly documented and told me that's what's going on. Then my complexity is going to be moderate. I've got personally going to interpret an image or maybe I could have three unique tests. So my data might be moderate, but then what I end up doing is saying, well, right now, let's go conservative. Let's do ibuprofen. Why don't you try that physical therapy? See me back in a couple of weeks. So what's the risk on my management? They're pretty low. So moderate, moderate, and then my low is still going to come out to a moderate level, and that's going to be that 204 or 214. So that's kind of how it looks like or the mathematics if you want to say. Next slide. Time, we can kind of buzz through this fairly quickly because I think that I'm probably taking plenty of our time here. Time now encompasses pre-service, intra-service, post-service, and what that means is everything in the office, okay? Everything you did for that patient today, not face-to-face, it used to be face-to-face. Now everything you did, you the provider did, to prepare for that visit, to see the patient, document, whatever else you have to do afterwards, all of that comes together. And then that's how you choose your time. So communications, documenting, examining, counseling, reviewing previous notes, studies, as long as you're not separately billing for those studies, okay? So we don't want to double dip here, but all of that, you get to include all of that time. You're going to exclude the time separately, reportable services, whether it's a procedure or interpreting, you know, doing your interpret report on your x-ray that you're getting paid for separately, you've got to carve that time out. So don't include time in generalized teaching. So if you're just out there having general conversations with a group of residents or something or nursing students or something, no, that's not going to count either. And so you want to document those activities, and then with the time spent. Next slide. And here's our time then, timetables, they're fairly simple, and again, since now we don't have to worry about that whole greater than 50% counseling coordination of care, do away with that, do away with the whole face-to-face thing, you don't have to document that, and now you have a simple timetable to follow. So it's great. That was a blessing for them to do that. Next slide, please. Medical necessity. So at the end of the day, regardless of the amount of documentation or the time, it's got to make sense for the visit. You know, there's still times that I'm plugging this in, because we use an audit program, my company, my audit team uses a software program, and we're plugging it all in, and we're like, yep, it's a four, it's a four, but you read it, and you're like, really? You know, it kind of gives you heartburn a little bit sometimes, and it's really nice then when my provider has, you know, they build it out at maybe a level three, and I'm like, oh, thank you, because I've got to agree, no matter what that thing says, it seems like to me that's a level three visit. So you know, you still have to use that common sense, the medical necessity, and our software programs, you know, they're computers, and they don't have that common sense approach to things sometimes. So we always want to make sure it still makes sense for the visit and the context of it. Next slide. Okay, so I think that that's it. I think we're done. Thank you so much, Linda and Dr. Malani, our presenters today for this great presentation. Usually at this point is when we go into the question and answer, but this being a virtual environment, we are not able to take those live at this time. However, if you do have questions about anything we talked about, or anything related to billing and coding, go ahead and send an email to healthpolicyataapmnr.org. And we hope to address all of those in a future, very soon publication. And of course, we're always looking for member volunteers for our committee. So if you're ever interested in learning more, participating more in this type of activity, go ahead and email that address as well and let us know, but enjoy the rest of the conference.

Outpatient Coding

2022

billing and coding

telehealth encounters

procedural coding

documentation requirements

E&M coding guidelines

chronic condition status

decision-making

medical necessity