Hi, everyone, and welcome to the MedAxiom Coding Academy course and educational series. This session is on the basics of evaluation and management coding in cardiovascular services. My name is Nicole Knight, and I lead our Revenue Cycle Division, and I'm happy to be joining you today to go over this content. You will see in these first few slides, this is the MedAxiom disclaimer that simply states that this is for informational purposes only. And then we also have an AMA disclaimer, who is the writer of CPT, which provides all of our codes that we're going to be talking about today. We're going to cover four different areas today. So our objectives are to understand the key components of E&M coding, to review the most up-to-date guidelines, identify and discuss the documentation components, and just understand some overall principles of the E&M documentation to help with selecting your category of E&M services. So let's start with the principles. So prior to 2021, our E&M guidelines supported 1995 and 97 guidelines. In 21, they updated our office and outpatient E&M guidelines. And this year, in 2023, they have aligned all of the guidelines and have eliminated the use of the 1995 and 97 guidelines and the 21 guidelines. So today we're going to go over our one set of guidelines, which hopefully makes for selecting your E&M service easier. There are some principles that have not changed through these updates. One is around medical necessity. The AMA who writes the CPT codes has a definition around medical necessity, which focuses on the care that's provided to patients around preventing diagnosis, treating that patient, the clinical appropriateness around frequency, extent, the site of service, the type of service. When we talk about CMS, which is Medicare, that definition has not changed along with the AMAs. The CMS definition still remains that medical necessity is the overarching criteria. We think it's important to start off knowing that medical necessity is that overarching criteria to help understand how these guidelines have been aligned over the years. When we're making a decision on what code to select for visit services, we have to know what category are we in and what level within that category. When we talk about what category we're in, it really relates to the place of service of that patient. So are they inpatient hospital, outpatient hospital, office, or observation? And of course there's other statuses, but those are the primary ones we're going to talk about today. So our most common categories are in the office, new patients, established patients, and consult codes are still available, and these are for some non-Medicare carriers who still accept consult codes for payment. In the hospital, it's our initial visits or admission, subsequent visits, and also the consult codes that may be available for non-Medicare participants. From a credentialing perspective with Medicare, we have specialty codes. This has also not changed. These codes are updated every year. However, we do not have any new designated specialties for cardiovascular services as to date. These are the common ones that we recognize and that Medicare recognizes within cardiovascular and subspecialties. These are related to their taxonomy codes and how they're credentialed with Medicare. So cardiovascular disease would be cardiology, so those are for physicians. Interventional cardiology, cardiac EP physicians, our electrophysiologists, our nurse practitioners and PAs have their own specialty, or certified nurse, clinical nurse specialists have their own specialties. So these are some of the common ones in cardiovascular, but not an all-encompassing list. This is what drives what specialty your physician is credentialed as under their taxonomy code. So it's important to know within your organization what is their primary taxonomy code for when they are billing for services. Why does this matter? The definition of a new patient. So this varies by site or service and payer reimbursement. For a professional service that's defined as a face-to-face service rendered by a physician or a qualified NPP, CMS uses the term non-physician practitioner, which is our PAs and nurse practitioners. An update for this year and in our new guidelines is for inpatient services, a new patient is defined as a patient who's not received any professional service by a physician or NPP in the same group during their current stay. So when we talk about hospital services, this would be the definition of the new patient when it comes to if you're seeing that patient for their initial service. In the office outpatient setting, this has not changed. This is when a patient has been seen or received care of a professional service by a physician or an NP, same specialty within the same group during the prior three years. So that's only for office and outpatient services. Outpatient services may occur in the emergency room department. We have to remember that. And also in observation. So it's important to know what is the patient's place of service upon admission and what is the service that's being provided to that patient if they're new or established with the same specialty within your group. For nurse practitioners and PAs, they have their own designated specialty and are not subspecialized. They would fall under the specialty of the physician that they are providing the service and are working in collaboration with. For place of service, sometimes the final place of service of the patient is not defined, for instance, in the hospital until they're discharged. So they may go from observation to inpatient. So again, where did the face-to-face encounter occur and what was that patient's status of when they were admitted and discharged for hospital services? The admitting provider still does append a modifier AI. Generally, the cardiologist or anyone within the cardiovascular group is not the admitting physician. Normally, we're the consulting physician. So it's important to remember that when we talk about our admission codes, because more than one provider can bill for admission services. The provider who is the attending and the admitting provider is the provider who applies that AI modifier. For the guidelines this year, a couple of key takeaways. AMA published a statement that more than one E&M service may be reported on the same date by the same provider. We know that CMS has retained their policy that only one E&M service may be billed per calendar day by specialty. So it's important, depending on what's your provider's primary taxonomy code, if that patient receives a service distinctly that day, if they receive more than one service by a provider in the same group, same specialty, only one service may be billed. So in some instances, the AMA and the CMS language does not align. This is one of those examples. Common cardiovascular categories. So we're going to talk about what are some of the highlights of what happened this year to merge the E&M guidelines. So our observation codes have been aligned with our inpatient care service codes. So some of our observation codes have been deleted. Consult code groups have been retained, but CMS Medicare still does not reimburse for consult services, and this would include many of your Medicare Advantage plans, usually less than 15% of payers recognize and reimburse consult codes. Prolonged service codes have been revised, and there's some differences with the AMA guidance and the CMS guidance that we'll talk about. Home and resident services have some changes. Nursing facility codes have some changes. And then emergency department E&Ms will continue to be measured using medical decision making as the criteria for code selection. So the big change for 23 is we've deleted some observation services and merged those into our inpatient admission codes. We've aligned hospital services with our office and outpatient guidelines that they are determined based on medical decision making or time. For observation, there's still the general guidelines that are in place. They must have a minimum of eight hours to be considered observation. You're going to use the same codes for initials and subsequent visits, but the place of service is necessary. So that's our admission H&P codes that will now be used for observation services. If a patient's designated as an observation status, they don't necessarily have to be located in an observation unit. Some emergency rooms have observation beds. Some inpatient units have observation beds. Again, it goes back to the status of that patient. They have the same CMS guidelines for observation admitting physicians. So admitting physicians, attending physicians only bill for observation services. So we're going to talk about what consultants bill. And then CMS maintains their policy of eight to 24 hours that it remains in effect for observation services. So this is the CMS policy for the eight to 24 hour rule. So you can use this, it talks about the hospital length of stay, when they're discharged and the codes to bill. And you can see now with the updates, they point you to if they're less than eight hours, and they're discharged on the same calendar day as the admission or start of that observation, you would use the initial hospital service codes. So they've deleted the observation codes and they will point you to those services just as an example. When we look at what codes were deleted from observation, the codes on the left are our initial observation codes, our subsequent observation codes, and our discharge observation code. They now crosswalk to our regular discharge service codes, our initial H&P admission codes, and our subsequent rounding visits if the patient is an inpatient status. If the patient is an outpatient status, from a CMS perspective, and they are termed as outpatient, or you are the consulting physician and you're seeing them in consultation in an outpatient hospital setting, you're going to use the new patient office outpatient service codes and the established office outpatient subsequent visit codes. So that's a little different. So again, goes back to that place of service, where's the patient located, it's going to determine that category. And then we're going to get into what determines the level of service within that category. So knowing the specialty of your physician, the group alignment, the place of service of the patient will lead you to if their observation are inpatient or outpatient, which codes do I crosswalk to based on those guidelines. We do still have codes for same day admission and discharge services. These have not been deleted. These represent a patient that stays eight or more hours in observation, but are discharged and admitted on the same day. This is not very common in cardiology because again, we're not the attending or admitting physician. However, if your provider is the attending admitting and physician, they're deemed eight hours or more in an observation status on the same date of service, they're admitted and discharged documentation would support two encounters, and it would be billed by the attending physician based on the code for that service. If it's less than eight hours, it goes back to our initial admission codes. So this is particular to on the date of care, was that patient admitted and discharged by the attending provider? Did it exceed eight hours on the same date of care? For our discharge service codes, this is our 99238, which is 30 minutes or less, or our 99239, which is more than 30 minutes on the date of the encounter. For discharge services, the time is used to report the discharge service. It represents the time on the date of that encounter, which is a change for this year. So for discharge services, inpatient or observation, time must be documented. You should document the total time spent or clock time to represent if that time is less than 30 minutes or more than 30 minutes. It can be used by the qualified health professional, which is our NPPs or APPs. Discharge services are only billed by the admitting and attending provider. So if your physician was the consulting provider, you're not billing a discharge service code. If you see them on the day they're going home, you're going to bill a rounding visit, which is that 99231233, if they are inpatient observation status. So the attending physician, admitting physician, will bill for the observation because they billed for that admission with that AI modifier. Again, we still have codes available for the same date for if the patient was discharged and admitted on the same date. The discharge service codes do not have a medical decision-making component, so they can only be supported and billed based on the time that's documented. You should document the components of what you provided for their discharge management and their length of stay. However, the time is going to determine if you use the 3-8 versus the 3-9. Consultations, we mentioned that the AMA has retained these codes. There's no change to the CMS guidelines. The only thing that's changed, they did delete the lower-level consult codes because they're not utilized very frequently. But the codes still do exist for 99242-45 and 99252-55. They've just eliminated the level 1 service. If payers do not reimburse consults, it crosswalks either to the inpatient observation or office outpatient visit codes based on that patient's place of service. Emergency department services, these are used to report E&M services provided in the emergency room only. That's not new. Time cannot be used as a key criteria for code selection. Remember, these are used based on medical decision-making only. This existing codes remain for ER visits, and both the emergency room and critical care services may be reported on the same day. If you are the only physician seeing the patient in the emergency room and providing emergency room care, then you are the provider who's going to bill the emergency room service, the 99281-85. If you are the consulting provider and the patient is outpatient, then you're going to bill the initial or established office outpatient service codes. If the patient is admitted to an inpatient status or an observation status, you are going to bill the initial admission or rounding visit codes depending on your specialty or subspecialty. How do I determine my level of service? We talked about the category and the place of service and how that determines what codes that you use within that category. We talked about specialties and subspecialization, an overview of the new updates to our inpatient observation services. Now we're going to move to overall for office outpatient hospital observation. What determines that level of service? From my history and exam standpoint, these components no longer determine the level of service within the category. So chief complaint should be documented on all patients. That's not changed. Usually that's reflecting that medical necessity for the visit. Your HPI, history of present illness, your review of systems, past family social history, and exam defaults to what the clinician feels is medically appropriate and pertinent to the nature and extent of what that patient is being seen for on the day of that encounter. So when we're talking about what's going to determine my level of service, it's what's happening on that date of encounter, and it's not based on my exam, review of systems, HPI, past family social history anymore. That's the big change. It's aligned with our office and outpatient services in the hospital. So the physician determines what type of exam and what type of key components in these other areas need to be documented. What's going to determine my selection of my E&M service is my MDM, which is my medical decision making, or the total time of the service on the date of the encounter. So I can document either or to determine my level of service. When using medical decision making, which is the most common that's used to determine the level of service, you can see they've discontinued our 95 and 97 guidelines, and now our current guidelines that are effective in 23 represent that in order to qualify for medical decision making, you must meet two out of three of these unique requirements. One being the number and complexity of problems addressed. Two being the amount and complexity of data ordered, reviewed, and or analyzed. Three, the risk of complications and or morbidity or mortality of the patient management. So when I'm selecting my level of service, regardless of my setting, if it's based on medical decision making, I have to meet two out of three of these unique requirements. So it is a bit of a change from 95 and 97, because if you know, remember in 95 and 97, we had to have so many exam elements, so many history elements, then we had to meet two out of three of the medical decision making on our table of risks. So a little different now. So we're going to break this down by each of these unique requirements. This is our overall medical decision making table. So the first column represents the level of medical decision making, straightforward, low, moderate, high. That is unchanged. Based on two out of three of the elements in number and complexity of problems addressed, amount and complexity of data, and risk, this is what is going to meet that particular level of medical decision making. So for instance, if I'm looking at a patient in that moderate section, I could have a patient who has one or more chronic illnesses with exacerbation, or two or more stable chronic illnesses. So let's just say I have a patient with two stable chronic illnesses, then I would meet the number and complexity of problems. If I go to my risk column, which is the last column, and that patient who has those two or more stable conditions, I'm doing prescription drug management. So I am telling them to continue, they have hyperlipidemia, it's stable, I'm going to tell them to continue their Lipitor, I'm doing prescription drug management. So in the moderate category, I've met the number and complexity of problems and the risk. So I'm able to code this as moderate. We're going to go through each of these sections and talk about some examples. But the important key categories are knowing that you have to meet two out of three. So if you only meet one in the high section, and you meet one or two in the moderate section, then that patient would be moderate. If you meet one in the limited section, one in the moderate section and one in the high section, then that patient is going to meet what the low category because it's two out of three components. So it's important to note that as we go into these new guidelines that you have to meet two out of three. Also under our data category, which is the middle category, you'll see that there's different categories under there. And based on if it's moderate or high, you have to meet for moderate at least one out of three of these categories to meet your data requirement. And for high, you have to meet two out of three of these categories. So if data is going to be a driving point to reach your medical decision making, then you have to be sure that you meet two if you're going to meet high in order to count data along with your other category. And in moderate, you have to meet one of these categories, then you would have to meet either number and complexity of problems or risk. All right, so let's talk about number and complexity of problems addressed at the encounter. So remember, this is the date of the encounter. So when I'm seeing the patients, you only want to list the conditions or comorbidities that are considered in selecting the level of E&M service. So this could come from your problem list. Now, again, if you list them, we don't want to just list the problems. It's necessary, that second bullet, to address the conditions. So you want to document the complexity, the risk, to support the medical decision making. We use that term meet for risk adjustment, manage, evaluate, assess, and treat. So when you're listing your conditions from your problem list, those conditions that were used on the date of the encounter to determine and support your medical decision making, treatment, and care have to be addressed in order to be counted towards your medical decision making. The evaluation and management and treatment should be consistent with the likely nature of the condition. So meaning if that patient's stable, progressing, improved, you want to be sure to describe that. The table that we went over is a guide to assist in selecting that level of E&M service. The final diagnosis does not in and of itself determine the complexity of risk. Sometimes an extensive evaluation may be required in, for example, a patient who has multiple symptoms. So they may not have a final diagnosis yet, but what is the care and treatment being provided to that patient on the day of this encounter, and what is their risk? That's what we need in our documentation if we don't have a final diagnosis. Typically, this information is in our assessment and plan where we have the conditions listed, and we're addressing those conditions and talking about our complexity and treatment for those conditions. However, it can be documented anywhere within the note. You just want to be sure that it's relative to that patient's visit for that day. When we talk about the amount and our complexity of data to be reviewed and analyzed, we talked about the different categories. So a couple of call-outs. Each unique test or order, which is defined by CPT, counts as one point. However, if tests are included in a panel, it only counts as one test. So what do we mean by this? If you have a physician that orders a lipid panel, it may be based on four lab results, but a lipid panel is considered one test. If you have a patient who the physician orders a lipid panel, CBC, and CHEM-7, that would be three unique tests. They have multiple components of those tests, but that is three orders. If a lab is ordered, it's implied that that lab will be reviewed. So you cannot count both the order and review of that lab separately. So on the day I order the lab, I'm counting that lab. If you come in the next day and see the patient, regardless of the setting, and you review the lab you ordered the day prior, you cannot count that as a data point. Diagnostic tests are considered but not ordered does count. So you want to be sure that all of the tests that you considered as part of your medical decision making is documented. For Category 2, independent interpretation, the interpretation of a test for which you have not billed a CPT code for, or where it would be customary. So for instance, in Category 2, if I order an EKG, I get credit in Category 1 for ordering the EKG, but I won't get credit for interpretation of that EKG because I'm going to bill separately for my professional interpretation. For Category 3, an external physician or other qualified health professional is an individual who is not in the same group practice or is a different specialty or subspecialty. So this is relative to our physicians and our APPs. So if we have a discussion with a provider from a different specialty, then we are able to count that as part of our data in Category 3. An appropriate source definition, where it says that you have spoken to or obtained from an appropriate source information, this does not include the family or informal caregivers. The examples that are given by the AMA are a lawyer, case manager, if you're having a discussion with the police. The definitions are very important. As part of the Coding Essentials course, you do get a download of all of the definitions on our quick card that's available as well. And I encourage you to read all of those definitions as they can help if you are educating providers or you are a provider and documenting in relation to these different types of definitions. So our third category of medical decision making is risk. So when we talk about risk, a couple of call-outs under risk. In our moderate category under risk is prescription drug management. The AMA did put this out that there's no blanket guidance for services to represent specific levels of risk, and that the physician is responsible for assessing and documenting that level of risk. So when we talk about prescription drug management, the one call-out and takeaway here is simply reviewing a list of medication does not constitute prescription drug management. So if you check a box in your EMR system that you've reviewed your medication, that does not count as prescription drug management under the moderate risk category. However, if you refill medication, continue medication, add a new medication, discuss side effects of a medication, this does count towards prescription drug management. Some definitions around when we're talking about medical decision making and the difference between moderate versus high, which are our two common medical decision making categories in cardiovascular around surgery. So there's under the risk category, minor or major surgery, elective or emergent. Elective or emergent. So what has not changed is minor or major surgery is not classified by if they have a global package. So for instance, our pacemaker implants have a 90 day global package that does not make it automatically a major procedure. So what does determine a minor or major procedure? Well, if you think about elective versus emergent, an elective procedure is typically planned in advance and scheduled for weeks later. An emergency procedure is performed immediately with minimal delay. These procedures may be minor or major, and the overarching criteria of documentation is truly around the risk factors that are relevant to that patient and that procedure. So evidence-based risk calculators may be used, but they're not required in assessing that patient's risk. However, your documentation should support whether it is a minor or major procedure, an elective or emergent procedure, what puts that patient at an increased risk for that particular procedure. And that's what's going to define the difference between a moderate and a high level if it's on the medical decision-making of a surgical procedure. As an example, this is the moderate table. So this is only moderate and we blew it up a little bit. So if I have a patient that has an undiagnosed new problem with an uncertain prognosis, so they have a new problem, we're going to do a procedure on them. When you look at the examples under your moderate risk, it says decision regarding minor surgery with identified risk factors, decision regarding elective major surgery without identified risk factors. So the difference is going to be that second one. If you have a patient that's going to require major surgery and they have identified risk factors, that could bring their risk level to high. However, we have to remember you have to meet two out of three of the medical decision-making components. So even though I may meet high risk on the medical decision-making table, I still would have to meet that high risk on the number and complexity of problems or on the data. So for example, if I have that same patient has one undiagnosed new problem and they have three tests that are ordered. So I order their lab work and EKG, a chest x-ray in preparation for surgery. And that patient has a major surgery and it's a moderate risk, pretty straightforward. It's going to fall here. When we get to the high table that we're going to talk about, we'll talk about that difference with high and what's required in the number and complexity of problems and the data in order to get to that higher level of service. Now, as we move to the high level of service, one of the items under risk as an example is drug therapy requiring intensive monitoring for toxicity. A couple of things that have been clarified through the guidelines are that if they are receiving intensive monitoring for a therapeutic agent that has the potential to cause morbidity or death, this is considered a drug that requires intensive monitoring. However, just listing that drug and continue the medication does not represent that you are monitoring them for toxicity. So they specify that monitoring cannot be by history or exam, that it has to be performed with a lab test, a physiological test or imaging. And also your documentation in the encounter should reflect the monitoring of the patient, what's considered in the management of that patient to monitor that drug. So they give some examples, maybe monitoring for cytopenia in the use of an antineoplastic agent between those cycles. So I'm monitoring lab work to manage that patient and to determine that they are not cytopenic in order to continue that antineoplastic agent. So when I see that patient on the date of encounter, in order to meet that drug therapy requiring intensive monitoring, I have to document what is the drug, what is the risk to the patient and how am I monitoring that on the date of that encounter. And then that could fall into high risk on the risk table, but I still have to meet another area of medical decision-making. These are an example of some of the drugs that are monitored for toxicity. This does not include all of the drugs that could be considered here, but these are some that give some examples. For instance, that you have a patient that's on an anticoagulant and it's for prevention of thrombosis. So we know that we see documentation saying that the patient is on Coumadin to help with prevention of stroke from their atrial fib. And we're continuing to monitor their INR for being therapeutic. That would be an example. And it goes into a couple of others, but again, this is not an overarching list of the drugs that are considered for toxic monitoring, just an example. So here is our high medical decision-making table. So we talked about under the risk category, which is the fourth box, we have drug therapy requiring intensive monitoring. We have elective major surgery with identified risk factors. We also have emergency major surgery. We have consideration for hospitalization or de-escalation of care. So there's no doubt that these particular examples would fall into that high risk. However, when I'm seeing that patient on the day that I see them, do they have one or more chronic illnesses with severe exacerbation, progression, or side effects or acute or chronic illness that poses a threat to life in order for me to meet my number and complexity of problems. If they do not fall into this and they're rather stable today, say I'm rounding on them on day two, I'm managing their high risk drugs, but they're overall stable. They're not exacerbated or having any progression. They wouldn't meet it in number and complexity of problems. So will they meet it in data? So in order to meet data in the high category, you have to meet at least two out of three of the data categories. So if I order lab X-ray and an EKG, I would meet category one. I would then have to meet either category two or category three. So an example of this would be, I meet my category one, cause I order three tests. And then I discuss with that patient's surgeon, their condition, their results of their test, and how we're gonna manage that patient post-operatively. And I document that information. Then I would meet category three, discussion with an external physician or appropriate source that I did not separately bill for. So my documentation reflected that I had a conversation with the surgeon regarding their high-risk medication that we've been monitoring it. This is what we recommend after they have their procedure done. That meets category three. I've met category one with my three tests that I ordered today. And I also meet it in risk. So the key here is to remember, just because you meet it in one of these areas does not mean that your patient is automatically high, moderate, or low. You have to meet two out of three of the categories. And it's important that you're documenting those key findings. Remember your exam, your review of systems, your past family social history, none of those components are driving the level of service. It's solely this medical decision-making that we're talking about, or we're gonna transition and talk about time. So when we talk about time as opposed to medical decision-making, so you have two options. I bill based off of my documentation to support medical decision-making, or I document my time. So the guidelines for 95 and 97 go away. So what's included in the total visit time for that day for that visit? The only time that can be counted is the physician or the APP time. It can be the time used for preparing and seeing the patient, obtaining and reviewing the history, performing the exam, counsel and education, even care coordination with the family, ordering medication tests or procedures, referring or communicating with other professionals, even documenting your clinical information can be used in that total time. What cannot be used is travel, teaching that is general and not specific or limited to the patient that you're seeing on that day for this encounter. The performance of other services that you're billing for separately, such as an interpretation. So for instance, if you're doing an echo interpretation, you cannot bill for the time it took you to do that echo interpretation because you're gonna be billing for your professional service interpret that echo. So that time is not counted. You also cannot count the time of your clinical staff and you also cannot count overlapping time. If you're seeing a patient with your APP and you're both in the room at the same time, only one of you can count that time. The exact time must be documented or the clock time. You should avoid use of greater than 20 minutes or greater than 40 minutes. You should say, I spent 45 minutes or I spent from eight o'clock to 8.45. It does have to be specific when it's related to time. Then you also have to document what is included in that time for that service you are providing. Prolonged service codes are available if you're billing based on time and they have done some changes to this category. So prolonged services, if you're spending additional time dependent on what that time range is for the level of service you're providing. So they deleted some of our prolonged service codes. They revised some of the guidelines in the CPT book for our 99417 and our 99418. However, Medicare decided that they did not wanna use these codes. So they created their own G codes that represent prolonged services. And then they revised some guidelines for prolonged services other than the direct face-to-face E&M. So we were able to build these if you were doing some services other than the data service and not having direct patient contact. CMS, Medicare has designated these as invalid for 23 and many payers are following that same guideline. They've also revised some guidelines around prolonged clinical services and what that looks like. So what does that mean for cardiovascular services? So if you're going to bill prolonged services, the 99415 to 16, this represents clinical staff time during an E&M service in the office or outpatient setting, direct patient contact with physician supervision. So this is only able to be added after a face-to-face service by a physician or an APP. So they have to see them first. It requires a full 30 minutes of additional time on a high level of service only. So our 99205 or our 99215 that's provided by a physician or an NPP. You can't count the time that a patient is waiting in the office for test results or anywhere within the office. This is truly additional time that you are providing to that patient after the physician or APP visit level five. So we can see why these are a bit hard to obtain. For our 99417 and our 99418, these are, 17 is for outpatient services, 18 is for high level inpatient observation services. These are the ones that are not covered by Medicare. So these prolonged services are only able to be added to our high level services, regardless of the setting. And then Medicare has established these G0316 as their prolonged service code. And you can see the time threshold. So if I have a high level three admission, inpatient or observation, I would have to meet 105 minutes on that date of the visit. And this would be counting the physician NPP time spent within the time period. So very important when looking at these, they have to be used to represent fully completed 15 minute segments. I have not seen a lot of prolonged services billed in the cardiovascular space. The majority of our physicians do bill based on medical decision-making. Some bill based on time, if it makes sense, but usually it's not meeting this prolonged service level of care. All right. So we've recapped what are our 23 guidelines for office outpatient inpatient observation. So we have one set of guidelines dependent on the physician or APP and their specialty, dependent on the patient's place of service and dependent on medical decision-making or time is how we're supplementing that bill. We're gonna cover two categories now, billing for advanced practice providers, that's our APP services. And then we're gonna cover a little bit of teaching service physician guidelines. So Medicare has options for billing for our NPPs, which we call our APPs in a lot of instances for their services. So if you're billing directly under the NPP, they independently see the patient, they document the complete note and they bill it under their NPI number and are reimbursed at 85% of the Medicare physician fee schedule. If you're seeing a patient incident too, this is for a place of service 11 in your office only and certain criteria have to be met. There has to be an employment arrangement by the physician or the clinic group. It has to be incident to the physician's plan of care that's been established. So this is not used for new patients, new problems or a change in patient care. It does require direct supervision by a physician in the office. So whoever is providing that direct supervision in the office as the physician, the patient has an established plan of care, the employment arrangement is in place, the APP sees that patient, documents the established plan of care, who's the direct supervisor in the office and it's billed under the physician meeting the requirements, it's reimbursed at 100%. If none of these are met, then it can be billed under the nurse practitioner or PA and it's reimbursed at 85%. So incident two applies to office only and we need to remember some of our office clinics are hospital-based clinics. So incident two does not apply to any type of hospital service, outpatient or inpatient. Split shared however, does apply to outpatient or inpatient hospital services. So these are our places of service 19, 22, 21, 23, a couple of others in the hospital setting and this is relative for new established initial or subsequent E&M visits that meet the requirement. Split shared services can also be billed with critical care and certain skilled nursing facility services. What's required to bill split shared services? If the substantial portion of the documentation is met or more than half of the time is determined, that is who the billing provider is. So we'll talk a little bit about what that means. If the criteria is met, there's an FS modifier applied and depending on who met the criteria, it would be reimbursed 100% if billed under the physician or 85% if billed under the APP. One practitioner must have a face-to-face visit with the patient. So let's talk a little bit in detail about some of the payer differences and what that means. So private payers may have guidelines or other specific policies. They generally defer to the state law or scope of practice. Most do not credential the APPs, NPPs and they request you bill under the supervising physician. So it's important you know what payer when you're looking at incident to split shared or if your APP can build independently. Medicaid also may have different rules, generally have state specific guidelines. You would think they would follow Medicare guidelines but that is not the case. And it's important to know what they require around physician supervision documentation. So the guidelines we went over for billing independently as a nurse practitioner PA, incident to our split shared depend on what payer. Medicare is the official of those guidelines. So that would include Medicare, our Medicare Advantage plans generally follow those Medicare guidelines and some of your private payers may and some of your Medicaid may. So it's important to know what your payer is. For a place of service 11, we talked about office-based only. They have to meet that incident too. So it can only be applied to the office and non-facility clinic. It does not support new patient outpatient service codes. So the 99201 to 99205, it's furnished under that direct supervision. The patient must have an established treatment plan and must be an integral part of that physician service. The physician must be present providing that direct supervision and the APP must have an employment arrangement. For split shared services, we talked about these are for facility services, meaning our hospital, which can be inpatient, outpatient observation, critical care, emergency services. And what does the provider who is billing have to support? So in order to meet split shared service, if they're doing it based off the substantial portion, the billing provider must perform a component of the E&M service in its entirety. The billing provider's documentation must support the component that you choose for the level of service and the billing provider appends that modifier FS. So what we commonly see in this area is the APP will see the patient, provide a complete note. The physician goes and they may see the patient or collaborate with the APP on the date of the encounter. And the physician will document that they agree with that APP's note and that they perform the medical decision-making its entirety and then they document that medical decision-making. Therefore, the physician has performed the substantial portion. It can be billed under the physician to Medicare with that FS modifier and reimbursed at a hundred percent. For time, so similar to selecting your E&M category for split shared, you can use time or a component in its entirety to meet the substantial portion. Time is represented more than half the time of the encounter. So if it is more than half the total time of the encounter, that is who determines who is the billing provider. And the time and the facility setting must be utilized for that particular patient on the unit, the floor, at the bedside. And it should be preparing to see the patient, obtaining same documentation requirements of that provider being the APP, NPP, or the physician. And whoever documents that they spent more than half the time would be the billing provider to support split shared services and apply that FS modifier. Teaching physician guidance. This is our last category that we're gonna cover. So for our teaching physicians, we have a few definitions. Residents are individuals who participate in an improved graduate medical education program. You may see that initial GME. Usually they're referred to as interns or fellows. A student is truly someone who is not considered an intern or a resident and participates in an accredited educational program. So the difference is that Medicare does not, and majority of carriers do not pay for students that furnish services. However, they will pay for residents, interns, fellows. The teaching physician is the physician who involves the resident in his care of his or her patients on that day of the encounter. Some of the guidance, a critical or key portion is that part or parts of the service that the teaching physician determines is critical and a key portion has to be documented. So for purposes of Medicare, these terms are interchangeable so it can be documented that the teaching physician was present for this critical portion of the note or this key portion of the visit. And that can be included in the documentation by the resident or intern. The teaching physician is located in the same room as the patient and performs a face-to-face service. So they have to be physically present and they have to perform a critical or key portion of the visit. And this can be documented by the intern or fellow. So from a documentation perspective, just what we talked about, we have to have documentation to support that the physician was physically present during the key or critical portions of the service and participated in the management of that patient. The presence of a teaching physician during the service may be demonstrated in the notes by the resident nurse or physician. So the teaching physician can document it as well. The teaching physician is required to document their presence and participation, but does not have to re-document all the content of the service. So this is where we get into those attestation statements. So it is appropriate to have a teaching physician attestation statement to support that they were present and participated in the care. They may review and verify and sign notes in the medical records, which that is generally required rather than fully re-documenting all of the information. So they will document some sort of attestation normally, and then they would co-sign the note and date it for that particular date of service. It's billable under that teaching physician as an E&M service, and it's part of that patient's medical record. So a couple of key takeaways for our E&M documentation. If it isn't documented, it hasn't been done. So very important as we move forward with revised guidelines that have simplified this process, it has to be documented for that particular patient for that date of service. The medical record should always be complete and legible, which with our electronic medical records, that has not been an issue. However, you want to be cognizant of copying and pasting information that may be conflicting. Documentation of the encounter should always include the reason for the visit, what was my assessment, my clinical impression or diagnosis, my plan of care. And that's what should be included in order to select that category and my level of service based whether it's on medical decision-making or time, depending on the location of the service provider, the specialty of that physician, and that will drive my category. We have a couple of references to resources that are available to you. And then we will also be available for any questions at this email address. If you have any questions, you will do a quiz post the session, and we appreciate you attending our education session. Thank you.

evaluation and management coding

cardiovascular services

Nicole Knight

up-to-date guidelines

documentation components

medical necessity

coding guidelines

new patient

accurate documentation

billing for advanced practice providers