Hello, welcome to the recorded session, Sense and Sensibility, Navigating PM&R Billing and Coding with Finesse. I'm Lauren Shapiro. I am the incoming chair of the Reimbursement Policy Review Committee. I serve as the medical director of the Stroke Rehabilitation Program at Brooks Rehabilitation in Jacksonville, Florida. For today's session, I'll be joined by two true experts on matters of reimbursement in our field. The first is Carolyn Millett, who is the Director of Reimbursement and Regulatory Affairs with the AAPM&R. Later, you'll also hear from Clarice Sin, Division Chief of Pediatric Rehabilitation in the Department of PM&R at the University of Kentucky. Dr. Sin also serves as PM&R's alternate member on the AMA Relative Value Scale Update Committee, better known as the ROC. Here she is pictured with other academy leaders who represent our field very well on this extremely important committee. The speakers report having no relevant disclosures. The Reimbursement Policy Review Committee is currently planning future educational sessions on reimbursement issues. If you have any ideas for future sessions, please email them to healthpolicy at aapmnr.org. We would like to acknowledge those who provided input into the content of today's session. So our thanks go to participants in recent early career focus groups, those who responded to posts on social media and FIS forum with topic suggestions, and the other members of the Reimbursement Policy Review Committee. The objectives for today's session, we'll review how and when to use the G2211 code for longitudinal care in the outpatient setting. We'll provide clarifications regarding the use of the FS and 25 modifiers, as well as the care or case conference codes. And we'll update members on the conversion factor, status of telemedicine codes and acupuncture billing. I'll be back in a few minutes to talk about the G2211 code, but before I do, Carolyn will join us and will provide a general overview on G codes. I will say, until recently, I didn't really understand the difference between a G code and a purely numerical code. She'll review those differences and will also provide some information about other G codes that physiatrists tend to use quite often and may be useful to you as well. So I will hand things over now to Carolyn. My name is Carolyn Millett, and I'm the Director of Reimbursement and Regulatory Affairs with AAPMNR. I'm going to start today by taking you through a bit of background about a type of billing code commonly referred to as a G code. G codes are part of the Healthcare Common Procedural Coding System, or HCPCS, which was developed in the 1970s as a standardized system to capture medical procedures and services. HCPCS includes two subsets, or levels, Level 1 and Level 2. HCPCS Level 1 is the code set called Current Procedural Terminology, or CPT, which is maintained by the American Medical Association. HCPCS Level 2 is maintained by CMS and captures all of the services, supplies, and equipment not captured in CPT. The codes in HCPCS Level 2 are alphanumeric and consist of five digits starting with one alphabetical letter followed by four numeric digits. Codes that start with the letter G are just one subset of the HCPCS Level 2 system. CMS creates G codes when it identifies a gap in CPT for services that are covered under Medicare. There are several examples of different types of gaps Medicare may perceive in the CPT coding system. There are Medicare-specific benefits and programs which would not appropriately be described in CPT as they are not services covered by private payers. In this instance, Medicare creates one or more G codes to capture these Medicare benefits. Another example is when CMS disagrees with how the American Medical Association has described a service in CPT. This may be a disagreement in the code descriptor or in the guidelines for how a code should be used. CMS will create a G code describing that service in a way that they believe to be correct based on how Medicare interprets and covers that service. CMS will also sometimes create G codes for services that CPT has not had a chance to create codes for. In this case, CMS will delete the G code once the respective CPT code has been created. While G codes are most frequently used by Medicare, private payers will also sometimes adopt G codes for payment. When there is variability between Medicare and private payers with respect to which codes are or are not accepted, it creates confusion for physicians and coders, adding to an already burdensome documentation and billing process. Where possible, AAPM&R advocates for consistency in terms of use of codes. It is also worth noting that CMS has created G codes to help with tracking quality reporting under the Merit-Based Incentive Payment System, or MIPS, program. This slide includes some specific examples of commonly used or well-known G codes, which fit into the buckets described on the previous slide. Two examples of commonly used G codes come from standard Medicare benefit services, which would not necessarily make sense to include in the CPT codebook, since private payers do not cover these services exactly as described by Medicare. The initial preventive physical exam, or more commonly referred to as the Welcome to Medicare visit, is specifically defined in the Social Security Act and requires certain components in order to be billed. While it has the same components as some evaluation and management services, it is better defined as a separate code. This G code allows Medicare to track utilization specific to this service and allows it to be paid at a specific rate determined by Medicare. Similarly, the annual wellness visit has its own G code, one for the first year this service is provided and another not listed on this slide for all subsequent years. Similar to the Welcome to Medicare visit, this service is similar to E&M, but billed using a G code for better tracking and appropriate payment under Medicare. As a final example on this slide, there is a G code for prolonged services, which will be discussed more later in this session. There is a CPT code for prolonged services, however, CMS has disagreed with how CPT has defined the time for prolonged services. CMS therefore chose to create its own prolonged service G code with different definitions of when it's appropriate to bill. As previously mentioned, this type of inconsistency across payers creates significant potential for confusion. As we continue this presentation, we will share more about G codes that are applicable to PM&R. Knowing and understanding use of G codes ensures you are not missing opportunities to bill for the services you provide. If you're only familiar with CPT codes, you may miss out on reimbursable services under Medicare and under some private payers. Now that you're familiar with what a G code is, I'd like to share some examples of G codes that may be regularly used by PM&R. There are several types of services performed by PM&R physicians, which may be billed with G codes depending on the relevant payer. In the next few minutes, I'll walk through some of the G codes that PM&R physicians may not know are available. The CPT codebook includes evaluation and management codes for prolonged services, which CMS does not accept for payment. Prolonged services are services with a duration that is longer than the longest time of a standard E&M code. Medicare has implemented three G codes to account for prolonged services in different settings. In the outpatient or office setting, G2212 captures prolonged services at least 15 minutes beyond the maximum required time of an E&M visit. Billing for these services can be somewhat confusing based on CMS guidelines. For example, a level 5 new patient E&M code describes services of a total time of 60 to 74 minutes. Per CMS, prolonged service code G2212 can only be billed once the total time of the service passes an additional 15 minutes or reaches an 89-minute threshold. This code is currently, as of 2024, reimbursed at a national payment rate of $32.30. All reimbursement rates in this presentation are reflective of the 2024 national Medicare payment rates. National rates will vary, and certainly private payer rates may vary even further. Tables used in this slide and in a related slide are from a 2024 September Medicare Learning Network E&M Services Guide, which is found on the MLN website. CMS also has prolonged service codes for both the inpatient and nursing facility settings. Nationally, these codes are both reimbursed at $31.60. The interpretation of when these codes can be billed with respect to the time of the primary E&M code differs from the interpretation for office and outpatient E&M. I'll go into more detail about timing on the next slide. It is also worth noting that these codes specify that time can include both time with or without direct patient contact. This is consistent with how E&M time is defined for inpatient and nursing facility services. Here you can see the time thresholds for inpatient and nursing facility prolonged services. Though it is not clear in this table, the prolonged service codes can be billed multiple times based on duration of the encounter. Each additional 15 minutes is billed as a unit of the G-code. Another code that may be helpful to you is G-2252, which was added to HCPCS as a permanent code in 2022 to address ongoing healthcare needs in the evolving virtual care space. Telemedicine services will be described in more detail later in our presentation. This code, G-2252, is reimbursable at a national rate of $26.30. CMS implemented codes for chronic pain management in 2023. These codes reflect a monthly bundled payment for services provided, including care plan development, treatment management, medication management, and so forth. The requirements for billing these services are extensive. AAPMNR has assessed these codes, and we expect that for our average member, it is likely more appropriate to continue billing E&M services for chronic pain management rather than these G-codes. However, for our members with chronic pain management practices, these codes may include components that are reflective of your standard medical practice and therefore may be more attractive to bill. The base code, G-3002, is paid at $82.50 nationally, and the add-on code for each additional 15 minutes for calendar month is paid at $32.30 nationally. Depending on the patient and the intensity of the encounter, reimbursement using standard E&M codes may be comparable or even higher. It is also worth noting that CMS used to pay for chronic care management services using G-codes. This is no longer the case, as CPT now has codes for chronic management, which are paid for by Medicare. Next, Dr. Shapiro is going to walk through usage of a new code, G-2211. Hi, Lauren Shapiro. I am back to review G-2211. So first, what is it? It's an add-on code that went into effect for outpatient visits in 2024, and it's meant to be used in addition to codes 99202-5 and 99211-15. Its official descriptor is visit complexity inherent to evaluation and management associated with medical care services that serve as a continuing focal point for all needed healthcare services and or with medical care services that are part of ongoing care related to a patient's single serious condition or a complex condition, and we'll boil that down further in the slides to come. But first, why was it implemented? Well, there was support from CMS as well as a number of physician groups for the need to compensate physicians and other billing providers for the increased time and resources that they spend providing comprehensive care to patients over time. What is it worth? Well, for Medicare patients in 2024, it currently reimburses at $16.05. It has an RVU value of .33. However, not all payers are currently paying for this code. Who is? CMS is currently paying for it, and unfortunately, there's not an exhaustive comprehensive list out there at this time. I did reach out to my own institution's compliance office, and they did indicate that both Cigna and Aetna are paying for this code, and surprisingly to me, so were Humana and United. Unfortunately, neither Blue Cross Blue Shield or Workers' Comp are currently reimbursing it. When can you use it? Well, it can be used for new and established outpatients for E&M services. Then you're either the continuing focal point for all needed services, serving in sort of a primary care role, or you're giving ongoing care for a single serious condition or a complex condition, and that's probably more relevant to most of us in PM&R. Now the examples that CMS gives for this are sickle cell disease or HIV, certainly comorbid conditions that some of our patients have, but usually not conditions we're directly responsible for treating. I will, however, in a future slide, review some more PM&R-specific examples where this code can be indicated. CMS highlights that the most important information used to determine whether the add-on code could be billed is the relationship between the practitioner and the patient. The add-on code G2211 captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship. So basically, it's less about the diagnosis you're treating or the specialty of the practitioner or even the frequency with which you follow this patient and more about the nature of the relationship between the practitioner and the patient. And it's also important to note that no special documentation is required to use this add-on code, though I would certainly recommend indicating your plan for follow-up in your progress note. Let's talk for a minute about this code's utilization. Thus far, its utilization is behind that which was anticipated. There are a number of reasons why this probably is the case. There certainly was some confusion about who could use the code, particularly if it was relevant to those of us who were not providing primary care services. There were limited examples provided by CMS. It also was unclear and still a little bit unclear as to who is paying for it in terms of payers outside of CMS. And then, of course, anytime there's a new code, there is always a little bit of time that's necessary to get it built into the electronic medical records and the billing programs. CMS issued additional guidance in an FAQ kind of document on the use of this code in August of 2024. So now we have a little bit more information about when it's appropriate to use this code. And I would encourage those of you who are providing longitudinal outpatient care to really consider using this. Keep in mind, its implementation was partially responsible for the need to decrease the conversion factor for the purposes of budget neutrality, and we'll talk about that more later. But basically, because this code exists, you are now getting paid slightly less per RVU, so you very much should use this add-on code if you can. Some outpatient visits are not really appropriate for this code, so you shouldn't use it for any procedural appointments. CMS has said they will deny it if the 25 modifier is used for the encounter. You should also not use it when the relationship with the patient is of a time-limited nature, and the example CMS gives for this is that of treatment of an uncomplicated fracture, or if the practitioner is not going to take responsibility for the ongoing care of the patient. However, it should be noted that CMS has said if the patient will receive ongoing care from another in your team-based practice, it is permittable to use the code so long as other requirements are met. So let's say I'm a general PMR physician, and I don't typically see a lot of patients with spinal cord injury, but there's someone who really needs to get in with a PMR physician right away to adjust their bladder-bowel program, maybe treat some neuropathic pain or some spasticity, and you know this person's going to need ongoing care, and you're by a PMR specialist, and you think their care is best met over time by your colleague in the same group who's a spinal cord injury subspecialist. You can still go ahead and fill that G2211 code so long as you make it clear that this other doctor in your group with whom you form a kind of clinical team will be following the patient longitudinally. Let's review some other examples of cases where it's appropriate to use the G2211 code. And in fact, the next few examples that I give are all cases in which either I have used the code successfully or a colleague has used the code successfully and has gotten reimbursed. So the first case would be a woman recently discharged from the inpatient rehab unit following a stroke who's now transitioning to outpatient therapy, and you're planning to see her every couple of weeks for the first few months and then less frequently. You are now the focal point for her post-stroke recovery care and can build a G2211 code. The next example is a young adult man with cerebral palsy that you consistently see once or twice a year for spasticity management of a non-interventional nature, rehab needs, perhaps some equipment, school accommodation letters, et cetera. You are the focal point of his care for his cerebral palsy and can consider billing the g2211 code The next case a man with a chronic spinal cord injury that you see every few months for management of neuropathic pains spasticity bladder bowel needs and equipment needs You are the focal point of his care for his spinal cord injury, which is indeed a complex chronic serious condition and you should go ahead and bill the g2211 and finally an elderly woman with recent trans-tibial amputation That you're seeing frequently for management of her phantom pain residual limb care and prosthesis prescriptions That is very much Longitudinal care for serious conditions. So you should bill the g2211 Now here are two examples. I've sort of made up in that. I don't commonly treat these diagnoses and have not Heard confirmation yet, but I do think these are appropriate cases For use of the code. So a young man with long COVID you're seeing Monthly for symptom management and rehab needs you're providing longitudinal care. Go ahead Or a woman with chronic pain syndrome that you've been closely managing in clinic for years that you plan to continue to follow You can certainly try to use the g2211 code, but you should not use it for any procedural visits How about sometimes when you shouldn't use it so I know a lot of us provide Longitudinal care in our appointments for botulinum toxin injections unfortunately, because those are procedural visits and you would be using the 25 modifier would not be appropriate to use the G2211 code in that scenario You should also avoid using it in cases of straightforward Musculoskeletal injuries from which you expect the patient will heal relatively quickly like a simple strain You should also avoid using it If you are seeing a straightforward concussion case where the individual is demonstrating normal recovery that you don't anticipate That you'll need to follow long-term and then you know a final example of a time not to use it is if you are Doing like a one-time follow-up appointment to make sure nothing falls through the cracks For a patient you've discharged from inpatient rehab perhaps for debility from an acute medical illness from which they've recovered You know, particularly if you don't anticipate that they'll have any further we have needs that would not be an appropriate use of the code There are a lot of helpful documents out there that provide more information about this code the AAFP the family practice group has excellent resources available on their website As does Medicare Learning Network and then I referenced earlier CMS's FAQ that came out with clarification in August. You can see the website again here I'd also like to point out we have some very useful information on the Academy's website If you click on the quality and practice tab and then select G20 to 11 education You'll see a lot of information that can help you Decide whether or not to use this code. Thank you Hi, I'm back to discuss the FS modifier for split shared encounters with a non physician practitioner The FS modifier signifies that an inpatient evaluation and management encounter was split or shared by a physician and a non-physician Practitioner typically a PA or NP who are working within the same group The modifier should be included when submitting the CPT code. The FS modifier is not new However, CMS has issued some clarifications within the past year to help us better determine who should be the billing provider for such visits. Should it be the physician or the NPP? The billing provider must have performed the so-called substantive portion by meeting one of two current criteria The first is time-based in which the billing provider spends more than half of the total time of both the physician and NPP on the patient's care that day The second is by medical decision-making in which the billing provider develops or approves the management plans and assumes responsibility for the risks associated with that plan A few notes when using time as the basis for determining billing provider The total time should be used including all of the time spent on the patient's care on the day of the of the encounter Except for any time spent on separately billable services so for example, if you and a nurse practitioner were to round on a patient and Document and enter orders and maybe review some records all of that time should count towards total time However, if you were to return to see that patient later in the day and perform a peripheral joint injection or perhaps some botulinum toxin Injections the time spent doing the procedure should not count towards total time because it represents a separately billable service It's also important to note when both the physician and NPP see or discuss the patient together Only one can be credited for that joint period of time Also, if you're billing a prolonged service code you have to use time rather than medical decision-making to determine who performed the substantive portion of the visit a few notes on using medical decision-making as the basis for determining who is the billing provider the billing provider must personally perform any Independent test or image interpretation as well as any external discussions when they are used to determine the appropriate E&M level Both the physician and NPP can perform some components of the medical decision-making the physician may bill for split shared visits even when the NPP has Contributed to the decision-making and this is an area which CMS has clarified within the past year The physician must either personally document which elements of MDM they perform or include a statement attesting to that Which was documented by the NPP? Implementation of time as the only means of determining who would be the billing provider has now been delayed twice The AAP MNR has strongly opposed the time-only proposal and it's important that you recognize that you can still use medical decision-making to determine who the billing provider Also, remember that when an NPP serves as the billing provider for a split shared visit Provider for a split shared visit Medicare pays just 85% of what it would under the physician schedule There are a few important things to remember when documenting split shared visits CMS requires that the medical record identify the physician and NPP who perform the split shared visit and That the billing practitioner sign and date the documentation It's also important to note when the physician serves as the billing provider based on time The total time spent on the patient's care by the physician should be clearly documented With a number of minutes whenever possible It's recommended that when Documenting split shared visits that you use an attestation statement I included the attestation statement that I was using for these visits in an article in the Physiatrist last year But I do need to point out that I included the statement. The medical decision-making is entirely my own This statement is no longer necessary Following the clarifications made by CMS this year. You can simply say that you developed and or approved the management plan for further information on this topic please check out our past articles in the Physiatrist newsletter from March of 2023 and September of this year and I've listed some additional helpful resources. Thank you for your time My name is Clarice Sen and I am going to be talking about CPT modifier 25 Modifier 25 is one of the most common modifiers used by physiatrists as such. It is commonly misused a Modifier provides the means to report or to indicate that a performed service or Procedure was altered by some specific Circumstance but not changed in its definition or code Modifier 25 is a significant separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service And it is used when distinct services are performed on the same day Modifier 25 is used to indicate that a patient's condition required a significant separately identifiable evaluation and management service above and beyond that associated with another procedure or service Being reported by the same physician or other qualified health care professional on the same date This service must be above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure or service that was performed on that same date and it must be Substantiated by documentation in the patient's record that satisfies the relevant criteria For the respective EM service to be reported The EM service may be prompted by the symptom or condition for which the procedure and or service was provided As such different diagnoses are not required for reporting of the EM service on the same date This circumstance may be reported by adding modifier 25 to the appropriate level of EM service It is applied to the EM code when there is an evaluation done during an EM service In addition to a distinct separate service or procedure on the same day If that intervention can be completed in the same visit The patient is offered a more immediate resolution to their presenting problem Without having to return to the EM service Modifier 25 allows physicians to capture additional work done during the same visit Enabling more efficient use of time and potentially saving the patient an extra visit The following questions show whether an EM service justifies a post-operative or post-operative care The following questions show whether an EM service justifies the use of modifier 25 according to the CPT guidelines First, did the physician perform and document the level of medical decision-making Or total time necessary to report a problem-oriented office Or other outpatient EM service for the complaint or problem Next, could the work to address the complaint or problem stand alone as a reportable service? And did the physician perform extra work that went above and beyond the typical pre- or post-operative work associated with the procedure code If all of these are yes, then you can use modifier 25 Then you can use modifier 25 So modifier 25 is used to signify that when a separate identifiable EM service was performed Which can refer to either two EM services or a procedure plus an EM service Its use allows for two EM services or a procedure plus an EM service that are distinctly different The first example is If a patient presents with frequent headaches, an EM service is performed including the history, physical examination, and a treatment plan that includes prescription medication management However, during the physical examination tenderness is noted over the left occipital notch The physiatrist then performs a left greater occipital nerve block and bills for this using CPT code 64405 As well as the appropriate level EM code with modifier 25 appended to the EM code To note that this was a significant or separately identifiable service However, if that same patient was referred specifically for a greater occipital nerve block for headaches And pre-procedure EM visit was done on the same day with no additional management or other workup Only the injection code should be billed with the EM code The next example is a 45 year old male new patient who is being seen for assessment and management of shoulder pain The physician completes an evaluation consisting of a detailed history and detailed examination Radiographs of the shoulder are ordered and personally viewed A working diagnosis of rotator cuff tendonitis is formulated And a shoulder injection is recommended The EM service meets the criteria of a level 3 new patient Or CPT code 99203 Because the EM work of the office visit is above and beyond that included in the procedure The visit is considered separately reportable The same diagnosis can be used for both the office visit and the procedure It is strongly recommended that the documentation have a separate procedure report or paragraph for the injection Both the EM service and the procedure must be adequately documented in the patient's medical record Demonstrating the need for the separate EM service So what needs to be documented? First documentation must demonstrate the medical necessity of the EM service If possible physically separate the documentation for the preventative service or procedure Documentation should be able to support each service. For example the preventative service or procedure and the EM As though it was a standalone service In just a moment i'm going to turn things over to Dr. Sin who will walk us through the process of In just a moment i'm going to turn things over to Dr. Sin who will review the case conference codes When we put out requests for suggested topics For this presentation today a number of academy members had questions about the use of these codes And Dr. Sin and I had a conversation regarding our own utilization of these codes and we had very different practices I personally have not been using these codes, but I will I personally have not been using these codes, but I will acknowledge that they may be extraordinarily useful depending on your clinical practice I just include any time I spend in team conferences and family meetings Of course my total time for the day and I clearly document it if i'm billing based on time Keep in mind that the inpatient billing and coding rules and thresholds changed in 2023 So currently to bill a 99233 You should have spent 15 minutes total time on that patient's care But that total time is very inclusive of any time you spend not only face-to-face But also coordinating care having discussions behind the scenes So why is it that i'm not using these codes? Well I'm, I round on my patients every day At least during the week I am the primary service attending so I think one area in which these codes are really helpful are In situations where you may not be rounding every day, but may have a case conference on a day. You're not otherwise seeing the patient Our practice on our inpatient rehab unit is not to invite families to our team conference I think inviting families is a good thing particularly for pediatric patients, but it's just not something that we do And also my team conferences tend to be very short because my team huddles every day So most of the problems we've already kind of addressed. It's not uncommon for us to spend less than five minutes per patient And with team conference times that are so short. It really doesn't justify the use of these codes So now i'll turn things over to dr. Sin who will review these codes in detail Thank you My name is Clarice Sen and i'm going to be talking about medical team conferences In november of 2006 the cpt editorial panel created cpt code 99365 Which was for participation by a physician for a medical team conference with an interdisciplinary team of health care professionals Face-to-face with the patient and or family for 30 minutes or more as well as cpt code 99367 which was for participation by a physician for a medical team conference with an Interdisciplinary team of health care professionals for 30 minutes or more when the patient and or family were not present These two codes were used to differentiate Team conferences by a physician when the patient and or family is present And when they are not Later the cpt executive committee rescinded cpt code 99365 Stating that team conference services by the physician With the patient and or family present may be reported using the appropriate em codes Rather than using code 99365 Or using code 99366 which is for non-physician providers The cpt editorial panel also developed new codes corresponding to the non-physician services cpt code 99366 is used by non-physician qualified health care professional for a medical team conference With an interdisciplinary team of health care professionals that is face-to-face with the patient and or family For 30 minutes or more and cpt code 99368 that is used by a non-physician qualified health care professional For a medical team conference lasting 30 minutes or longer when the patient and or family are not present The main differentiating factor for these two codes is whether or not the patient and or family are present for the conference examples of a non-physician qualified health care professional Would include app's physical therapists occupational therapists speech therapists social workers and dietitians Medical team conferences include face-to-face participation By a minimum of three qualified health care professionals From different specialties or disciplines each of whom provides direct care to the patient With or without the presence of the patient and or family or caregiver The participants are actively involved in the patient's care And they are actively involved in the development revision coordination and implementation of health care services needed by that patient Reporting participants shall have performed a face-to-face evaluation or treatment of the patient within the previous 60 days So it does not have to occur on the same day Reporting participants shall document their participation in the team conference as well as their contributed information and subsequent treatment recommendations No more than one individual from the same specialty may report 99366 through 99368 at the same encounter The team conference starts at the beginning of the review on an individual and ends at the conclusion of the review The reporting participant shall be present for all time reported We will start with CPT code 99367 99367 This code can be used when there is a multidisciplinary meeting Where health care providers from various specialties convene to discuss a patient's care plan The purpose of the medical team conference is to address complex medical conditions that require input from multiple health care professionals The goal is to formulate a comprehensive And coordinated care plan to improve patient outcomes The patient and their family are not present for the conference Note that this can only be used when the conference lasts 30 minutes or longer So what needs to be documented? You're going to need to document who was present at the conference What was discussed? What decisions were made? A summary of the care plan and the time spent in the conference So This code can be used for medically complex patients who require coordination of care amongst multiple medical providers. I have commonly used this code for patients that I am consulted on in the ICU. The following example shows a patient who suffered a TBI and a spinal cord injury from a motor vehicle versus pedestrian accident. The following services were present. I then chose to list what PM&R issues that were discussed during the conference. Although there were discussions regarding the other specialists, they will be documenting their part. You may choose to include the whole discussion, but I usually just document my part of the conference. I tend to include the decision and care planning together, but you can decide how best to convey your message. And don't forget to include the time of the conference, remembering that it needs to be 30 minutes or longer. For CPT codes 99366 and 99368, these are the non-physician qualified healthcare professional codes. 99366 is for when the patient or family are present, and 99368 is for when the patient or the family is not present. The required documentation is the same as for code 99367, so please refer to the previous slides. So how do we bill for a medical team conference by a physician when the patient and or family are present? As stated previously, it can be billed with the appropriate EM code by billing for total time. You just want to make sure you include it in your documentation. This can be used on inpatient rehabilitation or during consultation. You can use total time when doing care conferences by adding an attestation to the daily note. This is an example of an attestation that can be used when documenting a team conference for a patient on a rehab unit. It lists the reason for the meeting, who was present, what topics were discussed, and any plans that were concluded from the meeting. The time for the conference was then added to the total time for the encounter of that day. Hello, this is Lauren Shapiro again. I'm back to provide an update for 2025 on the conversion factor. I know this can be a very upsetting topic for a lot of physicians, so I'm going to try to keep this section very brief. For those of you who are less familiar with Medicare payment policy, the conversion factor simply refers to the amount that Medicare pays per RVU, per relative value unit. At the time I'm recording this talk, in October of 2024, the current conversion factor is roughly $33.29. What that means is if you're in clinic and you're doing a follow-up visit and you bill a 99214, you would generate 1.92 RVUs. That service would be reimbursed at $63.91. Now let's say I have a patient on my inpatient rehab unit and I'm discharging them and it's a complicated discharge. It takes me more than 30 minutes. Well, I'll bill a 99239, which will generate 2.15 RVUs, and that would reimburse $71.57, which is quite a bit less than I'd pay for a haircut. You may have heard some rumblings earlier this year about the conversion factor. So what exactly happened? Well, at the start of the year, a 3.37% cut took effect. This was largely due to a reduction in a prior temporary update to the conversion factor, but also because of an adjustment due to budget neutrality to account for the new G-2211 add-on code that we discussed earlier. Fortunately, in March of 2024, Congress took action and they passed the Consolidated Appropriations Act. This included a 1.68% update to at least partially offset this otherwise quite drastic cut. So you may ask, why is budget neutrality even a thing? Certainly we've seen inflation in all other sectors of our economy, and I wouldn't expect it necessarily to get cheaper to provide quality care over time. Well, you can blame the Omnibus Budget Reconciliation Act of 1989. As described on the AMA website, this requires changes in RVUs resulting from changes in medical practice, coding, new data, or the addition of new services cannot cause Medicare Part B expenditures to differ by more than $20 million from the spending level that would occur in the absence of such changes. So the addition of that G-2211 code necessitated adjustments in the conversion factor because we needed to achieve budget neutrality in these Medicare Part B expenditures. What's going to happen next year? Well, those temporary 2024 updates are going to expire at the end of the year. So it has been proposed that we'll see a cut of 2.8%, bringing the conversion factor from roughly $33.29 to $32.36. So now I would earn less than $70 for that complex discharge from IRF. So it wouldn't even cover what it will cost me to check my bag to and from San Diego to get to the annual assembly. So what can you do about this? Well, you could cry. You could drop Medicare. But I would strongly encourage you all, if you haven't already done so, to contact your congressional representatives and ask them to take action before the end of the year to prevent further cuts to physician reimbursement. It really only takes a few minutes. You can use this link I have on the slide here, or you can click on the Advocacy tab from the AAPM&R's website, and we'll bring you right there. While you're on that page, please also consider asking them to pass prior authorization reform. You can also ask your patients and your loved ones to contact their congressional leadership because we very much need to preserve access to quality care for our Medicare beneficiaries. Thank you. Again, this is Carolyn Millett. The next topic for our session is telemedicine coding and billing. This is intended as an overview of what is a complex and challenging topic. Further exploration of your specific payer policies is needed to ensure correct coding and documentation. While telemedicine has been in existence for decades, the frequency and applicability of telemedicine increased substantially during the COVID-19 pandemic. While many physicians have reverted to exclusively offering in-person care, telemedicine has a role in the future of healthcare. Whether you are a physician interested in offering telemedicine exclusively, or whether your practice is required to offer a few telemedicine visits each month based on patient demand, understanding how to bill for telehealth is critical for most physicians. One of the biggest barriers to broader adoption of telehealth has been the inconsistency in billing requirements. Billing guidance varies based on payers, and regulations have been in flux over the past several years. Without certainty around reimbursement, it is hard for a physician or practice to invest in telehealth. 2025 is a big year for telehealth coverage changes. Many pandemic-related flexibilities are ending, and code changes may occur. Since this is an evolving issue, we strongly recommend monitoring AAPM&R news for additional details about how to bill for telehealth services in 2025. Medicare has paid for telehealth services for many decades. However, there have been restrictions in place which significantly limited the use of telehealth more broadly with Medicare patients. Prior to the pandemic, Medicare payment for telehealth was limited to patients in healthcare professional shortage areas. Many Medicare beneficiaries are in healthcare professional shortage areas. However, this restriction required providers to be aware of the patient's home location and whether the patient met this requirement. It also excluded many beneficiaries from telehealth coverage. Further, patients could only access telehealth services at an approved originating site such as a community hospital. Beneficiaries could not access telehealth care from their home. Additionally, when receiving a telehealth service, a patient would need to be presented by a qualified provider, often a nurse. While CMS would pay a fee to the originating site, these burdensome requirements limited the number of services provided via telemedicine. Finally, Medicare has not historically paid for telehealth services provided via audio-only technology. This was another very limiting factor. At the beginning of the pandemic, several waivers were put in place which extended the ability for providers to offer telehealth to Medicare beneficiaries. Some of the most significant changes address the problems I outlined on the last slide. Under the waivers, telehealth services are available to beneficiaries in all geographic areas rather than only in rural areas. Additionally, Medicare beneficiaries may receive telehealth in their home rather than traveling to a healthcare facility. This removal of the distance site requirement was obviously crucial during the pandemic. Medicare waivers also allowed for certain telehealth services to be provided as audio-only telehealth. These waivers were all first implemented in 2020 and were set to expire earlier but were extended through December 31, 2024. AAPMNR has advocated for making these waivers permanent, a step which would require action by Congress. However, no extension or permanent legislation is in place at the time this session is being recorded. Without these flexibilities in place, Medicare coverage of telehealth will revert to being very limited in 2025. Medicare has permanently expanded telehealth access for mental health services, opening the door for future expansion for other services. In the years leading up to the pandemic, with the development of technology and companies like Teladoc bringing telehealth services more directly to the consumer, private payers began expanding their coverage of telehealth services. With the onset of the pandemic, private payers quickly pivoted to reimbursing more broadly for telehealth to account for social distancing. However, unlike Medicare, many private payers started scaling back their coverage of telehealth in 2022. Most payers are still broadly covering telehealth, but they have worked to establish more permanent policies, providing some stability with telehealth coverage, which is helpful for providers. That said, private payers are monitoring utilization and the potential for overutilization. They are also closely monitoring Medicare policy on telehealth and may shift policies on Medicare decisions in the coming years. Billing a telehealth encounter can be complex. For a standard audio-video encounter that would replace an in-person office visit, E&M codes are used to capture the service. As with all information in this presentation, different payers may have different requirements, but E&M is standard. There are many other codes for individual services that may also be reimbursable as telehealth. For example, inpatient and skilled nursing facility encounters may be reimbursable as telehealth by certain payers. Additionally, some PT services have been reimbursable as telehealth since the pandemic as well. In some instances, a telehealth encounter does not require the use of a visual component. Some payers offer coverage of audio-only telehealth or telephone E&M using a couple of different coding and billing mechanisms. For many payers, audio-only telehealth is covered using standard office and outpatient E&M coding with a modifier 93 or a modifier FQ to indicate that the service is audio-only. CPT established telephone codes for telephone services years ago. They have not historically been paid, but have been paid under the pandemic. There are three telephone codes in CPT which are divided up based on the duration of the conversation. These are listed on this slide. This is yet another instance where it's critical that practices know the coverage policies of the payers they work with in order to ensure they are billing correctly. Some payers will accept standard E&M for telephone visits, whereas others will require use of the telephone codes in CPT. Certain payers will require use of place of service codes to indicate that a service is being provided via telehealth. Some payers require the use of either Place of Service 02 or Place of Service 10. Place of Service 02 is used for telehealth services if the patient is not in their home when the service is being conducted. The alternative would be Place of Service 10, which is used if the patient is in their home. If a payer does not require use of Place of Service 02 or 10, they are likely looking for you to bill the place of service for where the service would have been provided in person. For example, a typical office or outpatient visit would be Place of Service 10 for office. Several codes are in place to capture virtual care, which is not either audio-only or audio-visual telehealth. Several G codes are in place for virtual check-ins. G2012, for example, describes a virtual check-in of 5 to 10 minutes, which does not meet requirements of an E&M service and does not lead to an E&M service within 24 hours. G2252, which was described earlier in this presentation, is similar to G2012, but is of a duration of 11 to 20 minutes. In both instances, these codes cannot be used when the service is provided by a nurse or front office staff. These codes are specifically used by physicians or qualified healthcare professionals who can bill E&M services independently. G2010 is somewhat different. This is an asynchronous code used for remote evaluation of video or images submitted by an established patient. Again, this code cannot be used when the service leads to an E&M visit within 24 hours. The online digital E&M code set is found within CPT and describes services which meet requirements of an E&M but are provided entirely through online communication technologies. These services are time-based and are for use only with established patients when the communication is initiated by the patient. The online communication technologies must be HIPAA compliant and secure. For example, a patient portal dialogue between a patient and a physician. Similar to the G codes previously described, these codes cannot be used when the dialogue leads to an E&M visit. Finally, I wanted to share a bit of information about remote therapeutic monitoring services, or RTM. RTM for musculoskeletal treatment is an emerging area with codes established for these services in 2022. Patients receiving physical therapy treatment can complete a portion or the entirety of their therapies virtually with the aid of a monitoring technology which allows the providers to monitor adherence and performance. There are billable codes for setting the patient up with the device as well as for monitoring the therapy. There are several significant unknown areas ahead in 2025 related to telehealth. As previously described, widespread Medicare coverage is unlikely in early 2025 due to expiring waivers. But due to beneficiary interest and specialty society advocacy, we are hopeful that legislation expanding telehealth for Medicare will come in 2025. Another interesting development is that the American Medical Association CPT panel has developed a new set of codes specifically for telemedicine encounters. The code set mirrors office and outpatient E&M. If implemented, it could remove some of the confusion related to modifiers in place of service codes used to indicate a service is provided by a telehealth. As of the proposed Medicare physician fee schedule, Medicare was not intending to pay for this new code set. Rather, it recommended continued use of standard E&M for all telehealth encounters. But that may change in the final rule. Private payers may also adopt these codes. Because so much related to telehealth coding and billing for 2025 is in flux, I recommend watching for more timely updates from AAPMNR in your weekly connections email newsletter. Next and final topic for our session is acupuncture. Recently, the American Medical Association Relative Value Scale Update Committee, or RUC, revalued the codes for acupuncture. The chart on this slide documents the changes to reimbursement between current 2024 payment and the new proposed 2025 payment. Please keep in mind that the 2025 payment includes the decreased rate of payment associated with the conversion factor cut, which is a negative 2.8%, as described by Lauren Shapiro earlier in this presentation. The changes to these codes will not be very significant as a result of the revaluation. The most significant change is for code 97813, which describes acupuncture with electrical stimulation. This code is increasing by $2 even with the proposed conversion factor cut. While these codes are not used by all PNR physicians, we did want to highlight these changes. On behalf of myself, Dr. Lauren Shapiro, and Dr. Clarice Sin, thank you so much for your time today. If you have any questions about the contents of this presentation, please contact us at healthpolicy at aapmr.org with any questions.

PM&R billing

coding issues

G2211 code

FS modifiers

25 modifier

Medicare telehealth

reimbursement practices

conversion factor

telemedicine billing

acupuncture coding