Hi everyone and welcome to our webcast. This is our first session on our boot camp. I'm joined by Jolene Bruder who is a revenue cycle consultant with our team and one of my astounding co-workers that I'm happy to be presenting with today. Hey Jolene, how are you? Good Nicole, thank you. All right, well we're going to go ahead and get started. This is the first boot camp session on the 23 CPT coding changes and the Medicare Physician Fee Schedule final rule impacts as it relates to cardiovascular services. My name is Nicole Knight and I'm the Executive Vice President of Revenue Cycle Solutions and Care Transformation. So glad to see that we have so many folks joining us today. A few informational slides as we get started. Under our new academy platform you do use the Zoom Q&A button for any questions that you would like to ask throughout the webcast. In the chat box you will find the link to access the presentation. This is in a PDF format and it can be downloaded and saved to your computer as well. Please use the question and answer session and know we have several sessions this week. Our session three that Jamie and I are doing is going to get deep into the evaluation and management guidelines. This is just covering from an aspect of CPT changes because we want to be sure Jolene has time to cover procedures and other CPT changes that are happening for next year. When claiming your CEU credits, you have to do this by going to the MedAxium Academy, clicking on the coding boot camp webinar that you attended, and click claim your CEU. CEUs are only awarded for live attendance and only if you individually registered. Just as a reminder, we do have the AAPC CEUs and if you need BMSC CEUs, please email Jolene Bruder. Again, go to the academy and download your CEU certificate. These are no longer emailed out. Also, a couple of announcements that are effective as we go into the new year, into 23. We will be offering AAPC CEUs for four to six webinars on demand, meaning that you can register for the webinar, listen to it at a later date, but would be required to take a 15-question quiz in order to claim your CEUs. If you listen to the live presentation, you do not have to take the quiz. If you listen to it on demand and want to claim CEUs, you are required by AAPC to take the quiz. We will be announcing our webcast schedule first part of next year, and we will let everyone know which ones will be available for on demand. Also, we will be applying to AHIMA as a vendor to obtain CEUs for our webcast next year. This is something we've been asked about, and we have been approved as a vendor, and based on their requirements, some of the requirements of our webinars, most of them will be approved as AHIMA CEUs, and you will be notified of that as well. Due to the decrease, we have less than three individuals who have the BMSC CEUs. We will no longer offer those next year. That organization, it has become an administrative burden to obtain the CEUs from them. They don't have a solid process in place. It is my understanding that most of these organizations that have the smaller requirements do accept the AAPC CEUs. If you have any questions or concern, please email Jolene. We'll address those individually if this is something that is going to impact you into the new year. For this webcast, again, the handouts are available in the chat section in Zoom. Also, the recording should be available by the end of the week if you're looking for the recording. So we're going to get started on covering our CPT updates and the cardiovascular impacts. This is just an overall slide that talks about the editorial changes, the 225 new codes, 75 deletions, and 93 revisions. Of course, this is not all relative to cardiovascular, thank goodness, and we're just going to focus on those that impact us in our cardiovascular service lines and across our organizations. Just as a reminder that there is a code symbol list at the beginning of your CPT book, and they do have some additional edits that are within the CPT book. And this always helps me as I go through and I'm trying to determine what is new or just a revised language, or especially when you see this green with the two arrows that contains new or revised text, there is a ton of that within the E&M section as they've updated the guidelines. So just so you know, if it's truly a new code, or if it's just new or revised text, you can see they have audio only, telemedicine, they've added a couple of other things. And really, this just gives you a good guideline to go back to if you're looking at the symbols within your book. Also, our appendix, Appendix S is a new appendix that offers AI taxonomy for medical services and procedures. And then Appendix T is also for interactive audio only telemedicine services. Now remember, this is AMA CPT appendix, does not necessarily mean that payers cover some of these, but this is an appendix that allows you to do that. A reminder, you can go to Appendix B, and it has every summary of additions, deletions, and revisions to the CPT codes. It's very helpful if you're looking for something and want to really look at those symbols and see what's changed. And then also a reminder, Appendix A is our modifier section. All right, so let's dive into some of the 23 guidelines and updates on our evaluation and management services. So across the AMA CPT guidelines, there are new and revised text in regards to all of these changes of what they termed other E&M services. The basic format of E&M codes with levels of service are based on medical decision-making and time. That is what you're going to see as a lot of the text changes as you go through the E&M guidelines section. I thought it was interesting, they outlined under each E&M category, it's a unique code number, then the placeholder code number, and then the placeholder code number. I thought it was interesting, they outlined under each E&M category, it's a unique code number, then the place or type of service is specified, the content of the service is defined, and then the time is specified. So when you see a lot of items that have been stricken through or a lot of changes or edits, this is the format that they have gone to that supports the E&M section and to help with understanding some of those changes. The place of service and service type are defined by the location where the face-to-face encounter took place with the patient and or family or caregiver occurs. They did outline this in that section. So place of service, we have to remember, is where the face-to-face encounter occurred if it is a face-to-face encounter. And we'll talk a little bit about that as we talk about some of the changes with the CPT codes. For our new and established patients, one thing to remember is we're going over the AMA CPT changes. You'll see a little note on some of the slides where I talk about CMS has guideline differences. This is from what CMS outlined in the final rule. We will cover those in depth. We'll touch on a few of those as I go through this section. But again, this boot camp session is not intended for you to learn all of the new E&M guidelines. It's just to touch on what are those changes that are imperative to our cardiovascular space. QHCP is qualified healthcare clinical professional. So that's just an abbreviation for that very long term that they've added to the coding clarifications. When we look at a new or established patient, there's no change here from the ANA definition of a new or an established patient in this section. So when you look at it from an advanced practice nurse or physician standpoint, they did add this language in the AMA CPT book. When advanced practice nurses and physicians assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. This is also from a CMS specialty guideline difference. We put the note here because CMS clearly in the final rule talks about that nurse practitioners and physicians assistants have their own taxonomy code and are considered their own specialty. Also CMS references that they do recognize specialties, but not necessarily subspecialties. So really understanding what are those CMS specialty categories as opposed to the AMA reference. And this is what causes some of those problems that we have with our payers when it's a specialty or a subspecialization with the CMS guidelines. But again, our advanced practitioners and physician assistants are considered when they are working with the physician that they are that specialty. From an AMA perspective, and then from a Medicare perspective, they're classified as nurse practitioners or PAs. All right. This is the AMA decision tree. I've gotten a couple of questions about this. Again, AMA versus CMS. This is in the CPT book and talks about when to bill a new and established patient. And again, verify your CMS guidelines, check your local Medicare carriers. I would expect that in the first quarter of the year, we're going to see updates from all of our individual carriers, which we know sometimes deviate from National Medicare and across regions. And I'm sure they're going to update the CMS National E&M Guide as well. But this is from the AMA book, and it is not the CMS reference. But again, understanding specialty versus subspecialty, your payers, and your particular region or where this is going to come into play, and what National Medicare says. Another interesting piece around services reported separately. So they did do a clarification around the ordering and actual performance or interpretation of diagnostic tests and services during a patient encounter and what's included in the E&M. A test that doesn't require separate interpretation and are just test results only are analyzed as part of medical decision making, do not account as an independent interpretation, but may be counted as ordered or reviewed. Now, this is an area we want to watch our local Medicare payers for and really look at that definition. But this is clarified in the AMA CPT guidelines. I think it's important to note the interpretation of diagnostic testing, meaning if you're billing that professional component, and it should have a separately distinctly identifiable written report for it to be reported separately, which would allow your CPT code to be appended with a modifier on the E&M. And then if you're billing professional services only, they talk about that if applicable, the modifier 26 is appended. Not necessarily anything new here. But again, we've gone back and forth about what is the definition of independent interpretation? What is the definition of counting ordered versus reviewed? And then for diagnostic test, what is the diagnostic test category? And do we have a separate interpretation of the result if we are distinctly billing for that professional component? So AMA does outline that here. Again, we'll see some variation across payers. On the history and exam element, as we know, our services for hospital services and other E&M services are going to our 2021 guidelines of our office and outpatient visit services. It will be determined based on medical decision making or time. For a history and exam, they further clarify that the E&M services would include a medically appropriate history and physical, and that extent is determined by the provider. The care team may collect from the patient and caregiver, and it must be reviewed by the provider. So even though your staff collects that information, they do reference that it should be viewed by your provider. The extent of the history and physical exam is not an element that will select the level of service. So we are dependent on our medical decision making or time, depending on how the provider is billing for that service. It will be important to remember to review all of the definitions of that medical decision making. There were not changes in many of the definitions, but some of those that we'll call out in the presentation on Wednesday when we go into detail, but also if you're looking at specific guidance based on that patient and what should be there. It does not have to be documented within a particular section in the note. I think that's very important. We're often asked about that. Just because we're billing based on medical decision making does not mean that the entirety of the medical decision making has to be in that assessment and plan. So it's getting used to as a coder looking at that note in totality and determining which sections support the medical decision making and our time. So we talked about this. It will be selected on our medical decision making and time. When we talk about medical decision making, that's defined for each service at the time of that encounter on that day. The total time of the E&M service performed is the date of the encounter. So again, we'll go into details around those specifics and selecting and we'll also have some examples. A few things from the final rule with regard to E&M information. So if you read all the comments in the final rule, which can tend to make you a little crazy, you'll see that they went back and forth. The bottom line is they're essentially adopting the AMA E&M documentation guidelines updates. They did not adopt the revised prolonged service codes. They're implementing their own G code. The CMS did comment a lot about what we talked about, revisiting the NPP or non-physician practitioners, which is your nurse, sorry, your nurse practitioners and PAs, the specialty taxonomy codes. They're going to consider better alignment with clinical practice, but for right now they're retaining the recognition of NPPs as their own designated specialty. They're also retaining from the final rule, the eight to 24 hour policies, which they have a table available and this is around both observation services and our inpatient services and those codes that have been combined. CMS still does not recognize and reimburse consult codes. I think our payers that recognize consult codes has decreased drastically, but there are still some that do recognize it. I would say in most regions of the country that we work with, it's probably less than 10%. But there are still some entities that do recognize consult codes. The consult code language has been revised in the guidelines. We're not going to get into detail of that today. It's not recognized by CMS. However, if you bill consult services, you may want to just take a peek at that revised language. Nothing really that impactful from a perspective of the overall definition and concept of the consultation services. So from our AMA CPT highlights observation inpatient and care service codes have been deleted and consolidated into existing hospital care codes. The consult group codes have been retained with streamlined guidelines and realignment of the medical decision making levels. And again, I have a CMS guideline difference because they still don't recognize consults. Prolonged service codes were revised and had the deletion of some direct patient contact codes in addition of a new code. The CMS guidelines again will have their own G codes. The home and residence E&M changes have included the deletion of some of the codes around the rest home codes. In addition, the services have been merged with existing home visit codes. Some revisions to our nursing facility E&Ms and our emergency department E&Ms will continue to be measured using medical decision making as the key criteria for code selection. So for E&M services for the emergency department, there is no time element. It is based solely on the medical decision-making. When we look at, sorry about that. When we look at the hospital inpatient and observation care services, I thought this table was very helpful. When you look at what our categories of E&M services were in 22, as opposed to what our categories are in 23, this helps with that. And then on this slide, it just shows what are some of the deletions for 23 and what is our crosswalk? So for instance, for 99217, which was our OBS care discharge, what codes do you report for that effective January 1st? It would be our regular discharge service codes. Again, they've been combined. Same thing when you look at those initial OBS codes or the subsequent OBS visits. Those have all been combined into our initial H&P admission codes or our subsequent rounding codes. So looking at it, if you've billed a lot of observation services and looking at the definition of OBS, what that means, what are the guidelines for CMS around the eight to 24 hour rule, still reporting your place of service and what that crosswalk looks like. Prolonged services, talked a little bit about that. Medicare will have its own G-code and then there's some deletion of codes and revisions and then adding to the new prolonged service codes. One thing that's important to remember when we dive into the time component of E&M services is that the code verbiage is meet or exceeds the time. So it's very important when you look at time-based services that you're looking at the language of those codes and CMS clearly defines in the final rule it's meet or exceeds that time. Now there are some codes as we know that can be reported based on time only such as critical care and it has other components of course that make it critical care services but that is a time-driven code. Our discharge service codes are time-driven, not medical decision-making driven. So when you're looking at prolonged services and when we dive into time, we'll talk about what are those scenarios, what are the time thresholds of where critical care would apply in our world and how that would be used. Just a couple of call-outs before I turn it over to Jolene. There is an edit in the E&M care planning code, the 99483. They had on here typically 50 minutes of total time is spent on the date of the encounter. They changed that to 60 minutes of time spent on the day of the encounter and these are all the activities that can be included in that. So if this is a service you built, wanna be sure that you're looking at that timeline requirement. And then for our transitional care management services, they basically updated the language as it's based on medical decision-making over the service period and what defines that medical decision-making. So just some wording changes here, but again, you wanna be sure that you're capturing these services as you look at your E&M programs and your care management services across the organization. I'm gonna turn it over to Jolene now so she can take us into the CPT changes, particular to procedures and surgeries. Jolene. Thank you so much, Nicole. We cannot wait for Wednesday for you and Jamie to cover all this stuff in depth. If you guys give me one second while I get my slides set up here. Here we go. All right. So now we're gonna talk about the CPT changes themselves. This first group that we're gonna talk about is for congenital conditions. And these are new codes for 2023 and these are when stents are placed in the pulmonary arteries. Now, the first code 33-900 is for an initial stent that is done unilaterally. So either right or left. And then this is coded in the case where the patient has normal native connections. Now, if you think back earlier, well, actually last year at this time, we had all those new aortic codes that talked about normal and abnormal connections. And basically what they're talking about is whether or not the blood follows the normal pathways. So this first set of codes are, we have the initial stent, like I said, for unilaterally, then 33-902 is unilateral with abnormal connections, or I'm sorry, 33-901 is normal native bilaterally. So that would be if you do both right and left, and these are normal native connections. And then 33-902 and 33-903 are unilateral or bilateral. And again, that's with abnormal connections. For 33-904, this is each additional vessel or separate lesion. Now, you can use that with the 36-900 to the 36-903. And it doesn't matter on that add-on code whether or not the connections are normal or abnormal, but it does state, when I looked in the MUE, the medically unlikely edits section in CMS, they're only showing this as one MUE. So as of now, from what I can tell, again, I don't have that crystal ball. I don't know if that will change, but as of now, you can build the add-on code up to one time. Let's see, what else? And then again, those normal native connections, that's defined as a superior vena cava, inferior vena cava, and that's the blood flow into the right atrium, then to the right ventricle, then through the pulmonary arteries. For abnormal conditions, now those can be, even if they've been surgically corrected, so if they've had the Blalock tossing shunt or a Sano shunt or a post Glenn or a Fontan procedures, the patient was born with abnormal connections. So those connections, even if they've been surgically corrected, that started out as a congenital malformation. So keep that in mind. For these codes, they do include access, cath placements, any guide wire manipulation, fluoroscopy, angiography for road mapping, checking of any stent placement, and ballooning to deliver that stent, and any supervision and interpretation. So that's all included. Now, if you have a true diagnostic angiography that is billable at the time of stent placement. Now, keep in mind, again, this is, the patient did not have a study, or if they did have a study, it's documented that the imaging was not readable or whatever that case may be, or it could be the patient's condition has changed since that last study. Or again, if there's a clinical change during the procedure that requires an evaluation. So that's pretty much standard across the board when it comes to diagnostic angiography done with any intervention, no matter really what we're talking about. And then also on this balloon angioplasty within the same target lesion as the stent is not separately reported. So, you know, again, that's pretty standard. If they do have a distinct lesion or in a different artery, then you could code the 92997 or the 92998. Those are your normal pulmonary codes, angiography, sorry, angioplasty codes for the pulmonary. For transcatheter intracardiac shunt, creation by a stent placement for congenital cardiac anomalies, excuse the typo there, that should say to establish effective intracardiac flow, then you need to look at codes 33745 and 33746. So there is a question that has popped up and said, are these for congenital only? That's the section they fall under the CPT book. And so, yes, I would say that these are congenital conditions only. So let's go to some regular cardiology codes. So the 93568, which is our pulmonary angiography that's done in conjunction with caths, this has actually been revised and they've added the words non-selective and they added the words arterial. And then of course, there's an extensive list here on what these add on to. It is considered an add-on code. It does not require the 51 modifier because it is an add-on. So with that, they revised this and here's why, because they've added all these selective codes for pulmonary angiography. So for 93569, we have unilateral pulmonary artery angiography, 93573 is for bilateral. Notice 93574 is for selective venous and the CPT book listed as angiography, but I would have preferred that as venography, but they didn't ask me when they wrote the book. Now I do want to point out, because we've talked to some physicians and presented some of these coding changes to them. And the question came up, can we use the 93574 with our EP procedures? Because they do the, they look at the, they do pulmonary venous angiography before they do their ablations. The answer to that question is no. That is considered road mapping for that ablation. So you would not code the 93574 with those EP studies. Also note that with the venous venography, the pulmonary vein as of now also shows an MUE of four. So you could report this up to four times. And then 93575 has an MUE of one and is pulmonary angiography of major aorta, pulmonary collateral arteries that are rising off of the aorta. So again, from what we're seeing in the medically unlikely edits, this one will only be reported once, the 93575. Note that these codes do include selective introduction and positioning of those catheters. So don't bill for the cath placement separately. That's pretty standard. It includes any injection. And of course, as always, it includes a radiological supervision and interpretation. All right. So now we're moving on. So we don't have a ton of cardiology changes this year. Now, this one can actually, that I'm getting ready to talk about, this is arterial venous fistula creation percutaneously. Now keep in mind, normally, I won't say normally, these can be done either by a vascular surgeon or an interventional surgeon. Our regular AV fistula creation that's done openly is normally only done by a vascular surgeon, possibly CT surgeon. But once they're cutting open into those vessels, interventionalists don't do that. So there are new codes this year. We have 36836, which is creation of those arterial venous fistulas through a single access. It would be both the peripheral artery and the peripheral vein. Again, this is gonna include any maturation procedure. If you have to do balloon angioplasty, any coil embolizations at the time, all that is going to be included as well as access and as well as any of your radiological supervision and interpretation. Now, code 36837 is, again, it's percutaneous creation of that AV fistula. And it is for the upper extremity. And that's the same with the 36836. These are both upper extremity only. And in the 37 code, you're actually gonna have separate access sites. So you'll have a percutaneous access site into the peripheral artery. And then one into the peripheral vein. And again, it's gonna include all the things that 36836 includes. Note, if they happen to do a percutaneous AV fistula creation in any site other than an upper extremity, you have to code this with an unlisted code. So keep that in mind. All right, so now we have revision to a code. And this will be the 35883. And this is actually, the code itself is a revision of a synthetic arterial bypass graft in the groin. This is an open procedure. So this would not be interventional cardiologists. This will be vascular, or it would be CT surgery because sometimes they get involved in this as well. Notice what they did is they changed the word Dacron to polyester. That's the only revision that was done to this. So just wanted to point that out. And now we have some fun category three codes. So these are codes that were deleted on this slide. So they did delete the 0497T and the 0498T. And these were electrocardiographic rhythm-derived event recorders that did not have 24-hour attendant monitoring. 97 was for the in-office connection and 98 was for the review and enter. If your providers are still performing this, you will have to, as of 2023, report this with an unlisted code 93799. This actually is our shockwave lithotripsy code. This is not new for 2023. It actually did come out in July of this year, which is the shockwave lithotripsy. It is used in conjunction with our other cardiac cath intervention codes. So your stents, your balloons, your atherectomies, through or within a bypass graft, acute MIs, CTO codes, all of that. Keep in mind if they do, because I know I'm gonna get asked this, if they do this in the extremity at this time, there is no different code to code for. There's no separate code for the lithotripsy for the extremities. So keep that in mind. Next, we have this cardiac acoustic waveform recording. Basically what this is, it's a coronary artery disease risk score procedure. It is done using a computer. A computer actually uses acoustic signal processing algorithms, and it will analyze the recording and identify specific heart sounds, such as S1, S2, murmurs, and things like that. And this could indicate that there is a risk for coronary artery disease. And this could indicate whether or not a patient has coronary artery disease. Keep in mind, because this is a category three code, like all category three codes, these are carrier price. And the carrier will determine whether or not they're going to cover these procedures. It is, however, important to report them, because this is the way that category three codes become category one. So the more they're being used, then they will create a category one code. So keep in mind, like the slide I had for the cardiac event recording device, obviously that wasn't reported enough. So they're dropping it from being a category three code, and that's why you're going to have to report those with the unlisted. So again, if this is something your providers are doing, please be sure and report them. And again, you will have to go on each and your individual carriers to find out what they're going to cover. Now, this is a group of codes that's for cardiac focal ablation, and this utilizes radiation therapy. So the 0745T is for non-invasive arrhythmia locations and mapping of the site. It is derived from anatomical imaging data that was gathered from either a CT and MRI or a myocardial perfusion scan, as well as a 12 lead EKG. And then what this will do, it'll identify areas to be avoided. 0746T is a conversion of the arrhythmia localization and mapping of the arrhythmia site into a multi-dimensional radiation treatment plan and then finally 0747T is cardiac focal ablation which actually delivers the radiation therapy. I don't know how much we'll be getting involved in that but it's out there and wanted to present. So this code 0744T is an insertion of a bioprosthetic valve. It's done through an open femoral vein. This does include duplex ultrasound imaging when performed. It includes any autogenous or non-autogenous patch graphs when performed and you would not report this code with 34501, 34510. The 76998 code which is usually our epiaortic ultrasound. Keep in mind this is um surgeon's probably going to do this as well. I actually have this under the wrong heading. It should be down under the next one so I apologize for that. Nor do you report it with a 93971. So it should have actually been under here but that's my fault. All right so we've also had a bunch of hernia codes deleted this year. 49560-61, 49565-66 and add-on code 49568 have all been deleted. They've also deleted the 70-72, 49580, 49582, 8587 and 49590. And a few more. These are the laparoscopic versions of the hernia codes that are also have all been deleted. And we now have new codes which I'm going to talk about now. So these new codes um the focus is no longer on what type of hernia do we have. Is it epigastric? Is it incisional? Is it ventral? Is it you know all those all those questions that we used to have to have that clear documentation on. Now it's mainly they're going to look at the approach. Is it open laparoscopic? I'm sorry no the focus is and nor do they care about the approach anymore either. So they don't care if it's open laparoscopic or robotic. These codes are now determined by whether or not they are an initial hernia and what size is that hernia. They also are determined by whether or not it's a reducible hernia or incarcerated or strangulate. So make sure your physicians are aware of this because you're going to have to know this in order to pick the correct code. You're going to have to know how big is this hernia and I would venture that most of them do not document that. So this is a discussion you're definitely going to have now before January hits because um you know you won't be able to code them if you don't know the size. So this first group we have less than three centimeters that's reducible again notice um initial is the word so there is a difference between whether or not it's initial or recurrent but um you also then need to know is it reducible incarcerated or strangulated and then again that size that size is very important. And these codes continue and again we're looking at size so now we have three centimeter to ten we have greater than ten for reducible and then we have greater than ten that's either incarcerated or strangulated. Somebody's asking why are hernia codes in the CV discussion because we also cover a lot of our members are CT surgery coders and CT surgeons normally perform these. Right and then this group of codes is for recurrent hernias. These are not initial they did re-sequence these as well that's why that number sign is there. And they you know basically they follow the same rules the size and then whether or not it's reducible incarcerated or strangulated. And again so on and so forth I'm not going to cover a ton of them. For this group this is actually um peristomal hernia and these um include um implantation of mesh or other prosthesis and then again it's broke out whether it's incarcerated or strangulated. There is also um removal of total non-infected mesh is reported with 49623 and you would use that in conjunction with codes 49591 through 49622. If the mesh itself is um infected then you're going to have to report that with code 11008 that's not a new code that's been around. So all right so some more category three codes again these are also performed by CT surgeons. We have the 0781 and 0782 um they're split out between bilateral and unilateral and you will only report these once regardless of how many treatments they do per the bronchus. And these are basically um destruction of radiofrequency destruction of pulmonary nerves and they include fluoroscopy guidance as well. Right that's all I really have on the changes um so we are going to have time for some questions. Um also this week so tomorrow Tammy Barron and I are actually going to cover some venous diagnostic and interventional procedures. There really were no changes for the venous codes but we do like to cover other things um during these boot camp sessions and this is one we haven't done in a while so Tammy and I will be tackling that one tomorrow. On Wednesday again Nicole and Jamie thank goodness um for them because I would break out in hives if I had to do this. They're going to do the deep dive into the 2023 evaluation and management changes and then Thursday we get Jamie and Nicole again for um they're going to cover some coding and reimbursement for our OBL facilities and ASCs so you know the ambulatory surgery centers or if you have that freestanding cath lab. Um keep in mind too this is our general case questions you can send to our rcs at medaxium.com that goes to the entire team and there's lots of us now and that allows us to all of us see this email and then you know we divide and conquer and try to get your questions answered for you faster. And then as always these are disclaimer slides basically that these are informational purposes only and these do not constitute any billing advice. As always you need to check with your particular medicare carrier and your commercial carriers and follow whatever guidelines that they're putting out. When in Rome do as the Romans and then also um all of these uh codes came from the CPT 2023 American Medical Association CPT book. All right so let's see some of these I think we've already answered. A question is will the 33900 and 33904 now be billed for stents in the pulmonary due to congenital instead of the 37236 237? Yes that is um these will take the place of those. Obviously those codes aren't going away because they're being used in in other areas of the body but um and these will be again for the congenital. So Jolene the 33900 to 33904 are only for congenital? Correct. Okay just wanted to clarify that. I saw a couple of questions on that. I see we have one about watchman procedure and a TEE being bundled or the procedures perform the TEE prior. There is a TEE code if the TEE is performed during the procedure by a different physician for our structural heart procedure. So I'm not sure Jolene if you read that differently or if we're talking about a TEE just a regular TEE that's being performed. I'm not sure I get the clarity on that question. Um normally you are correct Nicole that is the one that's done with structural heart. I'm not positive off the top of my head it's the I believe it's the 93355. I'm not positive if that is reported with the watchman right off the top of my head but if if that is the one it has to be a separate provider than the one that is performing the watchman. Um there's another question about the selective pulmonary angiography. Those are not for congenital um for the angiography codes. What they did is they had the 93568 which was our add-on code um those are not congenital only but um with the 93568 they revised that to basically state that it was non-selected and then they created the new codes 93569 so on and so forth for those selective pulmonary angiography codes. I see we have one about uh place of service for telehealth. So the question says what is the place of service for a mid-level provider providing telehealth in a different state than a patient? For example if you have a patient in one state but the servicing provider is in another state what I will tell you is that those guidelines are still under the public health emergency if you listen to our final rule webinar or not the public health emergency is still in effect till the middle of January. They are going to give us a 60-day notice prior to to terminating so we're within that 60 days so I'm guessing it's going to be extended again and then the telehealth regulations also have an extension after it ends of 151 days and I'm reluctant to answer that question because it is driven both by your state licensing boards and also the particular carrier so what I would tell you is with the PHE and the reason I bring that up is because there are some of those crossovers from state to state that did not apply under the public health emergency and it depends on your state and whether those have been lifted so that's one you got to look up according to your state and the practicing guidelines of your providers. The RCS email is if you have just general questions that need to be directed directly to us our listserv is where you should post questions if you want to hear from members which is a great place for us all to understand what's going on particularly as we talked about in the first quarter of the year has how many of the Medicare payers will be posting different guidelines and comments so please share on the listserv if you get any particular guidance around E&Ms or any other services from your payers and your region because members always love to hear about that and want to be on the lookout for their own particular region as well but that RCS email is if you have a question directly related to the RCS team that is covering the webinars this week and our team behind the scenes. Nicole I found a couple more. Let's see here so the 0715T the question is is this going to be a permanent code or is it going to change? I honestly don't know for now it's the category three so it's temporary it should tell you in the book again I don't have this right off the top of my head when it's supposed to sunset now sometimes just because something's slated to sunset doesn't mean they won't extend that I think it's usually three to five years from the year of creation but if it's used enough and you know just speaking from what little we have seen a lot of places are using the shockwave lithotripsy so hopefully it will become a category one code but and then once that happens of course a different code will be assigned and then the next question is if I could revisit the 36836 36837 is this for all percutaneous AV fistulas? It is for any AV fistula that's created in the upper extremities whether it be right or left arm if they if they put a fistula anywhere else would normally I've mainly only seen it if they're not doing the arms then they usually will place them in the legs if they're done in the legs and it is done by a percutaneous manner then we will have to code that with that unlisted code that was on the slide. Yeah and a lot of our temporary codes it is a process of gathering the data so I know we go through that in that previous question Jolene where we see that shockwave and other products in that lithotripsy area are being used and it's pretty normal that is part of our procedure now but it is part of gathering that data and moving through the progression to a category one CPT and I would say with the volume on that when you're right Jolene we'll see it but the question is we don't have any way to predict when that would happen unfortunately but I would imagine maybe next year. There's a question about the 99218 but they're also bringing up ASC and OBL I would leave that question for that date and yeah it most all of those 99218 the crosswalk is it does go to the observation inpatient category so it's all one code category right now so even though that code goes away depending on what you're using it I do not have anything around that convalescent care and transfer of care from an ASC but we will take that question when we talk about ASC and OBLs and and look at that so we'll look into that and see what we can find but for the question of 99218 it crosswalks over to our inpatient observation care codes that are all one category now and would be correspondent to 99221 so 99218 goes to 99221. And there's one more question on the 0715T which is our lithotripsy so if they if they use them if they do the lithotripsy in the balloon and balloon or stent in the SFA now you're talking lower extremity the 0715T is for coronaries only there is no recognized shock wave lithotripsy with the lower extremities and the peripherals or whether it be lower extremities arms anywhere else that they use it that code is strictly coronaries and as of now if they do shockwave lithotripsy in the SFA you would just report that as a normal balloon code. And I see someone posted about place of service whether it's OBS or initial we will cover from a CMS standpoint and also from a CPT standpoint but yes you will be if you remember I covered at the beginning that place of service doesn't change so you still have to code if it's observation if the patient's seen in the ED if the patient's seen inpatient you're still going to code the place of service where that face-to-face encounter occurred even though the category is one category now and that's where that 8 to 24 hour rule that CMS has set forth and marrying that with the AMA changes we'll talk about that in some scenarios as we go through that on Wednesday as well. I'm not really seeing any other questions in the poll are you? I don't think I see any other questions I think we'll give everybody a little time back as we continue to sort through the changes if we missed anything or if there was something that we didn't cover again this was meant to be high level overview of the 23 changes for CV and like Jolene says we service both congenital cardiovascular service line CT surgery vascular and all of our cardiology EP services so we wanted to combine it all in this session we'll get into detail in some particulars this week as we go through boot camp what we appreciate all of you joining us for this session and we look forward to the rest of the week.

CPT codes

2023

cardiovascular services

pulmonary artery stent placements

pulmonary angiography codes

arterial venous fistula creation codes

synthetic arterial bypass graft code

hernia codes

evaluation and management changes

AV fistula creation codes