getting started I'm going to go ahead and apologize because of course when we do these webcasts, particularly for boot camp it's impeccable timing so you may hear the garbage truck in the background because right on cue they came as I got started. And hopefully the FedEx guy spares us the beating on the door later so I apologize for that. Welcome to everyone it's great to see the numbers in attendance for our boot camp series that starts today. Today we're going to cover the 24 CPT coding changes, and some of the final rule highlights as it pertains to cardiovascular services. As many of you know my name is Nicole Knight, and I lead our revenue cycle division and I'm part of the care team. And I'm joined by Jolene Bruder who is one of the managers of the revenue cycle team as well so we're going to take you through some of the changes, updates, and hopefully you find this beneficial few housekeeping items before we get started. There is a handout available in the chat icon so if you click on the chat icon you'll see the presentation slides here and you can download those in PDF and save them. Also you have a Q&A button where you can type in questions as we go through the webcast. The entire RCS team which we are very happy to have are on the line and we will answer some questions as we go through the webcast. And if we have time at the end we'll take some as well so please feel free to type those questions as it pertains to the webcast topic today. Your CEUs will be available in your MedAxium Academy. Just remember everyone has to register for the webinar each one each day and you can claim your CEU certificate and download it from your MedAxium Academy login. All of these sessions are worth 1.5 CEUs and usually it takes a couple of business days to show up with the volume of webcasts we have over the next week. Maybe a little delay I don't anticipate but if your certificates aren't there within two weeks please feel free to reach out to us but they should be available shortly after the webcast. All right so we're going to get started on some of the summary of the additions deletions and revisions for our CPT. This is the legend of symbols as it pertains to new codes. Excuse me. Revised codes add-ons. So just a reminder to your symbols in your CPT book. I know I find myself I use an online version. A lot of my team use the paper version. They actually go through and excuse me. This helps you to know if it was a text revision or if it was something new and it is very helpful as you look at the color coding. So we're going to start with the evaluation and management services. A couple of items in this section that were updated. They removed the time ranges from office and outpatient visit codes. So this was our new patient codes and our established visit codes for both the office and the outpatient services. And they aligned the time ranges. So we're going to start with the evaluation and management services. And they aligned. them with the format for other E&M services. So basically what they did and we have a table that's an example in the next slide that shows instead of 15 to 29 minutes as an example they went to just 15 minutes with verbiage that you have to meet or exceed that time. So that's really the only change is that time range. If you remember CMS and AMA when we moved to time did not totally align on what those time ranges were and about meeting or exceeding and particularly as it pertained to prolonged services and other services. I think this is an attempt to align those time ranges. However CMS has not commented on prolonged services and as of right now we'll talk more about that in our session on Monday the 18th. However when you look in the AMA CPT book there's not any change to their guidelines on prolonged care. If you remember from CMS prolonged care is filled with some G codes and I anticipate it's going to be that you have to meet that time and exceed it by the 15 minutes. So if you build prolonged services stay tuned I'm sure we'll see some updates of that in January. But overall billing based on time for office and outpatient services will we have a chart that references that time frame. The definition of substantial portion has been outlined in CPT for split shared visits. We'll talk a little bit about that and some of the information we have around that from the final rule and also from CPT. Instructions for reporting hospital inpatient and observation care services and missing discharge services when you're using those admission discharge codes and staying over two calendar days. No real updates there just some clarification more than anything. So when you look at those two calendar dates there's some verbiage in there. I know we don't see those billed a lot because normally the cardiovascular physicians are not the admitting and discharging physician. So to observation. So just when you look at those two calendar dates and how that relates there are some language changes there. So here's an example of the time thresholds. So you'll see in as an example our 99204 our level four new patient was 45 to 59 minutes. They just went to 45 and the verbiage is that you must meet or exceed that time. So if you do have providers that bill based on time you want to be sure that they do document the time that's needed to meet this time or exceed it and they have to document total time or exact clock time not using terms greater than or those types of things. Time is very much clarified when it's based on supporting it on time only for your level of service. All right split shared service. What does this mean for medical decision documentation? This is from actually the AMA the CPT book and when you look in the introductory language it talks about this and it talks about if the physician or what they call the qualified health professional which is our APP's performs a substantial portion of the encounter they may report the service. So then it goes into talking about the definition of substantial portion. Obviously in 24 you still have two options. It did not move to time only so you do have an option for time. So who spent the majority of the face-to-face and non-face-to-face time performing the service and that's the time of either the physician or the APP if you're billing based on time and then they clarified the definition of substantial portion. When you look at the definition of substantial portion in CPT it talks about approval of the management plan for the number and complexity of problems addressed at the encounter taking responsibility for the risk and the complications morbidity and management of the patients. The caveat from CPT is by doing so the physician or the QHP that bills for the split shared services has to perform two of the three elements used in selection of the medical decision making. So prior to if you remember in 22 and 23 this year you could document the history exam or medical decision making in its entirety and that's who would bill for the split shared service. For next year in 24 that goes to your option is you can bill based on time or you can bill on who documents the medical decision making and that medical decision making of who the billing provider is is going to support the level of service. So this is where it gets a little sticky and we don't have clarification from our individual Medicare carriers. What we do have in the final rule is basically they postpone time and then they document a substantial part of the medical decision making and even reading hundreds of pages in the final rule it doesn't tell you exactly what that means. I will tell you in the complex E&M session on Monday we're going to go through some examples but what we know today is all we have is from what's in the AMA and what's in the final rule and not from our specific Medicare carriers. What we are seeing however is that if you're not using time it's based on who documents the medical decision making and that that medical decision making is supported and for the level of service meaning the provider who's going to be the billing provider who takes on the responsibility of the patient's care treatment and risk they have to document two out of three of the medical decision making components and that is going to be what levels the service. So a little difference particularly if you've been using exam which we have seen some programs use the exam as the part of the documentation that goes away in 24. It's either medical decision making or it's time only and many of you are part of big large organizations and I'm sure your compliance regulatory teams will be updating this information as well and I think we'll see some more clarification as we get into the new year with our Medicare carriers. What I will tell you the cleanest way to look at this is if the physician documents the medical decision making and it supports the level of service build then that will be billed under the physician. They never have accepted that they you agree with the above like they do with residents or fellows none of that has changed. I think it's going to be the tricky part is not going to be that they're not you know the medical decision making determines who's the billing provider is if they're documenting the substantial part of the medical decision making it's going to be that that's what's used to level the service. So how is that going to impact things based on that documentation? There is a new code for visit complexity services. What I will tell you this is finalized to be active on January 1st. Does have a work RV value of 0.33 which is about 16 dollars and some change. We've been very cautious about the information that we're giving on the visit complexity service code because the actual implementation of the code is closely linked to legislation that is trying to move forward to stop the conversion factor from being reduced. So if that passes in Washington then this more than likely will not be implemented on January 1st. What I will tell you is that all of Washington shuts down after this week so the chances of us knowing that that's going to happen or not I don't have much confidence in it so we probably won't know until January. The code is only applicable to office and outpatient visits. It's not billable when an E&M service the same day has a 25 on it so you got to think about that because a lot of the services we do have a modifier 25. It's a g-code for CMS and CMS stresses that from a documentation perspective it has to reflect the time intensity and resources involved in building longitudinal relationships with patients to address their needs for longer periods of times based on their conditions. There are instances and examples that they give that would make this applicable to some of our cardiovascular patients. I think the biggest thing is do you start billing this January 1st based on the information we have in the final rule only and what do you what do we see happening with this as we go into the new year. So we all know that many years the conversion factor changes and the legislation and the advocacy around that sometimes happens in the middle of January. We have take-backs we have all this we don't know if that's going to happen or not but again I think it's just something that we have to be aware of. It's very hard to train on something roll it out for January 1 for it to be taken away in a couple of weeks. So I think this is one where you've got to make the decision on what is what does it apply to within your organization and if you want to roll it out at the beginning of January under the auspice that it may not roll out. This happened with this code in 21 as well and it was stopped. We don't know like I said if it will be or not but just something to note as you're looking at new codes for the new year. There are also four new categories of new covered services. One is caregiver training, individual and group, community health illness management, social determinants of health, and principal illness navigation. I provided the codes and the work RBUs to you. Many the fee schedules we have not seen the actual fee schedules from some of the medicare's released. I'm not sure if yours has been released just share it with the group here and we'll or share it on the listserv when it comes out but these are g codes that were established by medicare and then the caregiver training codes are actually cpt codes. So we're going to talk a little bit about these and how they may apply to cardiovascular services and the opportunity. So for caregiver training these cpt codes are without the patient present and they talk about facilitating strategies and techniques around the performance of the patient's ADLs activities of daily living. So it's around transfers, mobility, communication, you can see the examples they give. They are time-based codes so there's a base code for an individual patient at an initial 30 minutes and then there's an additional code to supplement additional 15 minutes. There's also a group code that exists where you can do some of these group training sessions. When you think about these think about how you utilize potentially social workers, dietitians, pharmacy in your practices and some of the education and programs that they meet may be offering within your organization and are those opportunities to participate and build for these types of services. When you look at caregiver training they define who the caregiver is and pretty straightforward there. I think where we get into that this may look like it could support some of our programs in our organizations is the patients with chronic or other health conditions disabilities or functional limitations. So when you look at our congestive heart failure programs those types of programs is there a need and is there an opportunity to use these codes. Patient consent is required for the caregiver training and then CMS does suggest what might qualify for it and you can see where we would fit into that chronic illness category. It is they do have some around behavioral health but really when you look from a cardiovascular specific where do you fit from that chronic illness standpoint and really navigating the transitions of care here. So what does that look like? Time-based services so remember documentation and guidelines. Also medical necessity has to be determined and it determines the frequency of this as well so that's pretty vague. Again this is from the CPT and and final rule information not from our specific carriers yet. Social determinants of health is another category. It is a g-code. It is time-based. It does clarify that it can be billed every six months by a practitioner. It anticipates it can be done on the day of an E&M visit and billed along with that E&M visit. It does require an initiating visit. It's done under the supervision of a clinician so our APPs or physician by our but we can do it with our auxiliary personnel. So this is something that potentially if you're doing these types of risk assessments you do have to build the z codes that support social determinants of health and it talks about what that administration of the standardized evidence-based risk assessment tool looks like as well and what is it related to. I'm not too sure in your cardiovascular programs many of you have a lot of different types of programs where this may be applicable but it's important to look at that risk assessment tool what that means what that covers and is your program involved in those types of services. Community health illness same it is when you're doing the social determinants of health this addresses those needs so basically that initiating visit that's centered around those social determinants of health kind of leads you to this community health illness and it does talk about that it's provided by certified or trained auxiliary personnel under the direction of a physician or an APP or a community health worker and these are time-based again really dependent on the types of services and programs that this may support and if you're really in that social determinants of health and your particular specialty subspecialty and it does require reporting those z codes that support those social determinants. Principal illness navigation, not to be confused with principal care management. These are some additional codes that Medicare has provided in the final rule. They are G codes, and they are around providing some principal illness navigation by certified or trained auxiliary personnel. This is when they refer to navigators. So when you really look at these services, they are time-based and they are billed monthly. So you're getting into that 60 minutes per calendar month for that initial code and an additional 30 minutes per calendar month for the add-on code. It talks about it requires serious high-risk diseases expected to last three months or more, very similar to principal care management, but not to be confused with that. This identifies conditions such as COPD, congestive heart failure, which are applicable examples for us in that congestive heart failure space. And of course, there's several other conditions. It does have an initiating visit. And then there are some requirements that the auxiliary staff be certified or trained to provide all included principal illness navigation as per state law. So not sure state law, how that's defined in many instances, but when I think of these codes, I really think of the nurse navigator role and how that could be billed. CMS does state it's very similar to principal care management, but acknowledges more focused on the social aspects and values. And then it's under general supervision. It can be contracted to a third party. And you do report the applicable Z codes as well for this service. So as you're thinking about these four categories, it's taking us to think differently. And what I've been saying is as you bring these to your organization, think about how they could apply. Because as we look for reimbursement and we look for opportunities for our patient to provide team-based care and support all of the members of our team and resources, these are the opportunities that we're seeing more and more of become reimbursable services. I don't think any of us would say we're seeing that reimbursement is increasing for many of our procedure or diagnostic services. We're seeing that reimbursement move more towards the quality value of care as opposed to those diagnostic procedural services. So as you continue to navigate this, where we don't see a lot of use of chronic care management, principal care management, and many of these programs, as you can see, the reimbursement and what we're seeing coming forward is how can those team-based care coordination activities, navigators, social work, dieticians, our nurses, how does that play into the work we're doing and how does that look to support the quality and value of care moving forward? So really looking at all these programs, and I think you'll see a lot more to follow from Medaxium as we continue to dive into these and what that looks like across organizations and where that opportunity is. This is the tool that outlines the social determinants of health, and it does provide some good insight into how to identify that. So you can see where some of this may come into play depending on your community and your region. It may be something to consider, and if you're working in collaboration with other specialties in your programs and how this could help really looking at what that would look like across your organization. All right. So I'm going to dive in a little bit to a couple of procedures and stuff, and then Jolene's going to take us through a couple of other items as well. Good news for our interventionalists. We do have a new CPT code, 92972, that replaces the temporary code for coronary lithotripsy. There's a description of this code. It is valued at 2.97 work RVUs. It's to be used in conjunction with our interventional codes. They do clarify, which I have not seen it, that it's not billable with a diagnostic only with no intervention, so this is billable with an intervention, which is how we usually see this. So January 1st, this code goes into effect, and it replaces that T code, and it is going to be reimbursable and does have work RVUs assigned. I wanted to note and show an example. I've been impressed CPT has created these charts, and I know Jamie on our team took that, it might have been a year before last, and actually recreated the one with a little more clarification for EP, and we all use that when we're coding EP services. I did notice in the book there's one now for the cardiac cath. There's also one for devices, for implantable devices. So I think these tables are very helpful, particularly when you're coding these services and looking at what's included and what's not included and could be added on to ensure that you're capturing all of the services, and also to clarify what does that look like. But the add-on procedures, I find this very helpful as just a quick glance to know what adds on to what. We do have a CPT code as well for coronary FFR CT. This replaces the 0501T through the 08T, and that code is the 75580. For professional services, it has a work RBU of 0.75. It's used only once, and this replaces that FFR with CT on our professional service side. So again, when we get a CPT code and no longer using temporary codes, it often solves a lot of problems for reimbursement and also for productivity allocation for our providers. So just make note that this is another one that's effective for January 1st. So I'm going to go over, and there's a lot of detail in your handout. I'm not going to spend a lot of time reading this information to you, but I think it's important as we look at Category 3 codes, and then also newer CPT codes that are assigned that we're going to go through, that you really know the technology and the information. Not as much the company that makes it, but it does help. Sometimes we often call products by the company brand name. However, I wanted to talk about a couple of these and just being on the lookout as you look at your devices and when new things show up, because often the coders and the revenue cycle team are the last to know. So this is a device that's for a phrenic nerve stimulation for sleep apnea. The interesting part of this device is they actually talk about that it's placed minimally invasive as an outpatient procedure by a cardiologist. So I have not seen any of these in the groups we're working with, doesn't mean they're not being done. However, I think just being aware that we have some codes for this and what it is and what to be on the lookout for for that. And these are actual CPT codes. So these are around the insertion, and they talk about a pulse generator and a lead into the vessel, and it includes the guidance. And then as you can see, it's got some breakdowns of add-on codes and then the removal. If you're only doing the lead, if you're only doing the generator, if you're repositioning, if you're doing a removal and a replacement. So we have some CPT codes for this service. Not sure if anyone's providing this or seeing this, but I imagine if cardiologists are going to be the ones doing this or it's minimally invasive, I can imagine we're going to begin to see these. They are also codes for activation and interrogation as well. So then you have to think about how this is going to be done, because this is your interrogation and programming. What does that look like when the patient comes into your clinics? Are you doing the interrogation and programming? And you can see they have a code for one parameter, and then they get into interrogation without programming, therapy activation. So again, looking at when you see this or if you see this particular technology, just something that's out there, but they do have CPT codes for this particular one. For our Category 3 codes, like I said, know and understand your device. You're going to see information about wireless cardiac simulation systems for LV pacing. They actually in detail go through in the CPT book around what these are. These are for left ventricle, big left ventricular pacing functions by sensing right ventricular pacing output from a previously implanted conventional device, such as our pacemakers or defibrillators by V devices, and then it transmits an ultrasound pulse to our wireless electrode implanted on the endocardium of the left ventricle, and then it emits that pacing pulse. So these are in combination of the left ventricle and right ventricle pacemakers that provide bi-ventricular pacing. The complete system consists of a wireless endocardial left ventricular electrode and a generator. The generator has a transmitter and a battery, and then it talks about where the electrode is placed, and usually two subcutaneous pockets are created on the chest wall, one for the battery and one for the transmitter, and these two components are connected sub-Q tunneled cable. So again, what is the device you're using? What do the codes relate to that? And then we have some T codes, and these are new and revised codes. The red and the crossouts are what was revised in the language. Then it shows the new codes, again, you're going to see similar around the insertion, the removal, the relocation, depending on the service you're providing, but again, something to be on the lookout for as you get into this. And then the next couple of slides you'll see are around category three codes for leadless pacemaker insertions, the dual chamber leadless pacemaker insertions. So we have some T codes for this, and this is different technology than what we do see with the current, and there's some guidance around that. We did provide you with all of these new technology codes, and there is a lot of information. I thought the interesting thing was on this one is that it's a dual chamber pacemaker system that includes two pulse generators with a built-in battery and electrode. So when you think about it, there's two. So what does that look like? If you go online, you can see a couple of examples of that. And then we have codes, again, around the removal and depending on what you're removing. So all of these are specific to these devices, and then we have removal and replacement codes similar to our implantable devices as well, and gets into programming, gets into the single chamber pacemaker as well. So again, more T codes. What I will tell you is a couple of things to know and understand about this device as we move forward. This one does include a pulse generator with a built-in battery and electrode, and it's a transvenous, transcatheter approach. It talks about that for our right ventricular leadless pacemaker systems, we're using the CPT code 33274. That's the one we see around our micros, things like that. So again, knowing your technology, knowing the device, and understanding what this is for. So it's for those right ventricular leadless pacemakers systems that are transvenous access. So again, have the evaluation, you have the insertion and replacement removal codes. These are T codes, again, I'm sure we will see that as well. I do see that several folks are raising their hands. We cannot interact with you with raised hands. We can only interact with the Q&A box, because this is a webcast, we can't call on anyone to speak. So please just remember to type your question in the Q&A box, because if you raise your hand, we're not going to be able to call on you. So if you have a question, type it in as well. This is just some additional information around that leadless pacemaker system as it pertains to the device evaluation, and then also when a right heart cath may be billable with these services as well. And again, I think know your equipment, know what you're looking at, and where does it fit into these Category 3 codes. If they create a Category 3 code, it's important to utilize that in order to report the service and not try to fit it into a category where it does not fit, because that Category 3 code is to understand the utilization of that service so it can become a CPT code. So very important as you look at those new technologies. I'm going to turn it over to Jolene for a bit, who's going to cover a couple of additional procedure services, and is going to start with our congenital. Thank you so much, Nicole. I appreciate you especially going over the devices, because as any of you that know me know that EP and devices cause me hives. So I'm glad that I have a team that can cover that stuff too. So as far as the congenital codes, there's not a lot. They're all add-on, and it has to do with venography. And basically, a venogram is a test that basically uses an x-ray to create moving pictures of blood as it flows through the veins. Patients can use this to diagnose deep vein thrombosis when ultrasound images aren't sufficient. They're also used with congenital heart caths, and this is what we're going to talk about today. So we have these five add-on codes, and basically the first code, the 93584, that's for an anomalous or persistent superior vena cava. So that would be if you have a second superior vena cava to the right or left of the first one. Then in 93585, we have the isogous and hemisogous venous system. 93586 is for coronary sinus. And again, this is all with anomalies. And then we also have 93587, we have the veno-venous collaterals that originate at or above the heart. So if you think about the head and neck vessels, so from the heart up. And then we have the collaterals that are venous-venous below the heart. Next slide. So basically, some more guidance on these codes. So if you have those situations where they're doing the congenital heart cath codes, and IVC and SVC is actually normal, then you would still code those regular 75825 or 75827, depending on which part of the vena cava they're looking at. So keep that in mind, this does not replace anything that's normal, this will be for anything that's anomalous. The anomalous vessels are coded with those new add-on codes that was on the previous slide. And they do add on to our congenital right heart cath codes. So what that means is the congenital left heart cath, the 93595, does not allow for any of this venous add-on code to be billed with it. And basically, it's because the right side of the heart is coming off the vena cava. And that is the venous system that you'd be looking at. Where the left side, obviously, you know, you have the aorta and the arteries are all dumping in with the left side above the heart, so you, it does require that you have the right side that you're looking at. Also note that, so normally, if they would happen to do any selective venous or venograms, that you know, there are those cath places are not included in the right heart caths. However, with this group of add-on codes, they've actually bundled the cath placements into that. So you're not going to separately code for cath placements when you use these codes. So keep that in mind. Next slide. Actually go one more. So I want to talk about the new ultrasound codes, and this is mainly probably used by mainly your CT surgeons, not always, but for the most part. So for years, we have used the 76998, which was kind of just an ultrasound guidance intraoperative code. Now note that code has not been deleted, but if you're truly looking at the intra or the epiaortic and you're performing that ultrasound during a CABG or heart valve, open heart valve, you would use this code in those cases. Now, again, this is looking for, we're looking for the patency of that aorta. This is done to aid and bypass that type of thing. This is not, you would not use this code for mapping any of your CABG vessels. So and just that's the same rules with the 76998. So if they're doing that ultrasound, you know, if they, if once they put the vein grafts, they attach those to the heart and the aorta, and they do some type of imaging in that, this is not when you would use this code. This code is basically for that epiaortic, and it is diagnostic. Some other areas, and again, some of this is for congenital heart disease. We have the 76987, which is the epicardial cardiac ultrasound for congenital heart. And it does include placement and manipulation of the transducer, any imaging acquisition, and the interpretation and report. In 76998, that would be placement of that transducer and image acquisition only. And then in 76989, that would be the interp only. So it's going to depend on, you know, what all your physicians are performing, and they need to document that clearly. And again, keep in mind, the 76998 did not go away, you know, but it just seems like CPT wanted to have more specific cardiology options versus just a generic ultrasound guidance intraoperative. Next slide. And actually go one more. All right so there's a few category three codes I want to talk about. I'm not sure if you're going to be seeing any of these but in case you are there's a spectroscopy code the 0860T and this is basically a procedure that is done for screening for peripheral artery disease. Again that it's category three which means it's carrier priced and it does include provocative maneuvers, image acquisition, interpretation and report and it's for one or both of the lower extremities. So keep that in mind on that one. Next slide. So this one is a new structural heart cavi implantation which is a caval valve implantation. This is very interesting technology here. This one was actually new in July of this year but now that you know we have the new books it's actually covered in the the CPT book for 2024. The CPT book for 2024. Now some of you may or may not have seen any of this yet but basically what a cavi is it's a type of transcatheter therapy which is made up of two self-expanding valves that are inserted and advanced and deployed into the inferior and superior vena cava and that's they do this in order to either assist or replace the tricuspid valve. So you would see this for patients that have severe tricuspid regurgitation and heart failure. It does include a right and left heart cath unless it's truly diagnostic so again those of you that have been around cardiology for a while all of those diagnostic catheter based studies you know you have to meet there isn't a prior based catheter based study. If there has been one then it has to be documented in the record that either the images weren't readable or there's been a change since that study was done or if the patient has a change while you're actually performing the procedure. So those rules are across the board. When it comes to diagnostic any cath or angiography and it comes to any type of intervention. If it is truly diagnostic then of course bill it you will need to unbundle it with either a 59 or an x modifier depending on what your carrier wants you to use. We would not code the transeptal puncture that is not separately billable with these cavi procedures. Also note I didn't talk about this one is for a percutaneous femoral vein approach that's the first code the 0805 t and then the 0806 t is by open femoral vein approach. Also note that if the patient is placed on bypass you can report that separately with the same bypass codes that we use with the TAVRs and the TIMVRs and all of those wonderful acronyms that we have. All right Nicole next slide. And then this is the last category three this is probably going to affect the CT surgeons possibly it is for the esophagogastroduodenoscopy and this is used for it's a flexible transoral with volume adjustment of intragastric bariatric balloon. Your CT surgeons may or may not perform this it depends on what they get called in but since the esophagus does fall under CT surgery a lot of times those surgeons will get involved it just depends some of them it ends up the general surgeon but I did want to put it out there in case you run into this. Again it's carrier priced and it is a category three code so it will be up to the individual carriers to determine how they will reimburse and how much they will reimburse. All right back to you Nicole. All right thank you Jolene appreciate it and I'm so proud of you for being able to say those words with your your cute little accent. So so for the final fee schedule just a couple of highlights and we also did a webinar on this on December 4th it is recorded and available to listen to for available to listen to for a lot of details around both the Medicare physician fee schedule and the Ops outpatient hospital rule so if you didn't attend that there are slides and a recording for that but want to hit just a couple of things where we get questions. Appropriate use criteria has been rescinded and this will not happen unless there's new proposed legislation so this is definitely totally rescinded and they're looking for continued workable approaches but unless there's future rulemaking we won't see that coming up again. The next couple of slides are around a few of the other changes so this isn't a CPT change you know Medicare had a g-code for the technical portion of our loop recorders and our ICM devices for remote management so the G2066 was billed every 30 days for the technical management of that loop recorder or that ICM device for remote services so only had to do with those two particular devices it is being deleted as of January 1st and they've established inputs for the work into the CPT codes for 93297 and 93298 for our loop recorder remote management interpretation and our ICM so now that'll be a TCPC or a global code so this will impact billing Medicare for the technical component depending on how you bill if you bill globally then you would just bill the 93297 or 93298 if you split bill and you bill the professional service only you will have to add a modifier 26 to your 93297 and 98 and then depending on how you're either potentially contracted with the third party for your technical services or if you're billing those technical services or have a hospital outpatient department that would vary as well because now that technical component is no longer in that g-code it is in our CPT codes so very important you know our loop recorders are large volumes for remote management so really taking this and operationalizing this no change for the physician from a documentation perspective they're still doing an interp this is around that technical piece and really operationally you need to determine how you're capturing this and how you're billing for the service the next couple of slides are for telehealth services what I will tell you about telehealth services is that they did pass in the medicare physician fee schedule from the consolidated appropriations act that they extended some items through the end of next year so through the end of 24 when you get into telehealth specific services you should pull the CMS list of telehealth approved services on that list you'll see things that have been permanently added and things that still remain provisional so there's a lot around telehealth and what was changed when so just a couple of reminders around telehealth patients can receive telehealth services wherever they're located such as their home or any other setting that's allowed by their state many state laws around telehealth what services can be provided around licensure of the practitioners so you need to look at your particular state requirements from a medicare national perspective use of audio only meaning telephone only has to be billed starting with January 1st it's billable with the 99441 and 443 and this is how audio only is reported if you're providing true telehealth services through audio and video remember when the PHE expired it has to be a HIPAA compliant platform for audio video telehealth services for audio only next year they will continue to reimburse from a CMS perspective for this audio only does not mean that all payers will so again it's going to have some variability depending on your state and payer myths for calendar year 24 CMS will permit a distance size practitioner to use their currently enrolled practice address if you remember this they were going to require the physicians to report their home address if they were doing telehealth from home or wherever they were doing telehealth from this did not go through so where that physician or practitioner practices and is enrolled is going to be the address of the distance site practitioner the place of service is determined by the location of the patient place of service 10 effective January 1st 24 will be the patient's home and this represents a non-facility rate and then place of service to telehealth facility rate so this has that facility rate in it we no longer will bill modifier 95 um also for next year they are allowing direct supervision to include the presence and immediate availability of the supervising practitioner through audio and video so direct supervision can be provided between audio and video secure platforms so be sure that you're also looking at your state requirements a couple of things around cardiac rehab under hospitals without walls a patient home was allowed to serve as a provider-based hospital department for cardiac rehab services now that the phe is ended hospitals are required to provide cardiac rehab services within the hospital department codes for cardiac rehab were added to the list of medicare telehealth services on a provisional basis with flexibilities through the end of 24 so really looking at again that provisional and a reminder each state has its own rules for telehealth across state lines and many other requirements so please look at your state requirements from coding boot camp tomorrow jamie is going to take us through asc coding documentation and reimbursement and then thursday jolene and tammy are going to dive into some peripheral angiography and intervention and then on monday the 18th linda and i are going to have a session on complex enm coding and documentation and it'll vary across critical care to complex enm and we'll even dive into split share just a little bit um so we hope that you attend these informational sessions we are now going to open it up for questions and answers i'm going to move my question box over here so i can see here um when we are getting a lot of questions about do we have examples of substantive portion what if the physician and the doctor document the same medical decision making or the exact same um you know elements of the medical decision making what if the doctor does an addendum of the medical decision making and then the np does it i wish i had answers of clear black and white to those what i will tell you it says is the provider that performs the substantive part of the medical decision making that's going to determine the level of service is the billable provider so from my perspective and what we're seeing is that the physicians will be documenting the medical decision making if we're going to bill under the physician that's going to drive the level of service of the encounter i'm not sure how if a note went to medicare and the app had a completely documented medical decision making and the physician had a completely documented medical decision making without any type of statement um then how would they decide who's going to bill for it i think all of us can look at that as if you do reviews and you know how do you make a choice you know what happens operationally in your practices what i would tell you if you want to make it clear as you possibly can having the physician document the assessment and plan is what we've been hearing a lot of groups are doing uh and the app is documenting the other portions of the note um we're also seeing where particularly on rounding notes where you know it doesn't require a lot of words or a complete assessment and plan to reach the medical decision making so many times the physician is coming in after the app and documenting management and conditions and the risk of the patient and meeting levels of service i think it's going to depend on what you do operationally and we're going to have to wait on how some pairs um give us examples around that because as we know it exists now we see variability in that across all pairs jolene would you add anything to that am i am i missing something or no i think you covered that quite well it is something that comes up a lot and um i i had a physician the other day that asked me you know well what if what if my app actually came to me and i said well we're going to do this this this and this and then the app went back and put that in their note and i said well if you're the one that truly made that decision then you need to document that the decision was made entirely by you and what that was and then you're going to have to sign as well yes yes and i see we have a couple of questions around is there um an nct or in you know nct for the lead list category three pacemakers i don't have that information we are device agnostic meaning we support all devices and support basically cardiovascular patients across the spectrum i don't know there probably is one um i don't know if jamie will type an answer if she knows that there's one out there i can expect this is new technology and fda approval went out with many of these devices over the last few months so i'm sure um or from the beginning from the middle of the year so i'm sure there's a lot of information out there on them um i know when i looked at specific devices there's a lot of different information and truly collaborating with your ep position and understanding what that device mechanism is and what they're using it for and how it's implanted is going to be crucial as you're going through that hey nicole just to jump into um there is if you go to cms.gov there is uh in search for leadless pacemakers there's a lot of information on there yeah yeah there's a lot of coverage letters i know and things like that i saw um but there's a good good thing jamie thanks for letting us know that yeah they did add an updated one um october of this year so i would assume that probably applies to the dual um dual one okay um let's see we have anything else here for telehealth the places of service are going to go um into effect for next year places service 10 is the is the patient's home patient place service 2 is anything other than the home when you look it up and you look up all the telehealth information so that's uh how we're going to be reporting that and then the 95 goes away in 24. did you have something um i was just gonna say i am and some of you may or may not have seen it there was a question too about uh when the ct surgeon reports that they're doing that fe aortic ultrasound if they need to document what they found and not just what was done that is correct they have to document vessel patency any type of findings they find with that aorta it needs to be clear that they're not just checking for for example venus graphs and the blood flow within those graphs if during a cabbage um i don't know for sure yet i would imagine it's going to bundle i know the old code does um so you're probably going to have to unbundle that one as well someone did mention a device um a avier a v e i r d r ncts uh in the chat i i know i saw some information on that on google and they also put some of the nct numbers again i would just caution you to make sure which device category that falls into and which billing code it falls into you want to be sure that you're looking at those descriptions and uh 24 when those codes go into effect uh the the question and answer and and all the information in the recording will be published and sent out um are available on the academy um let's see can the app scribe on behalf of the billing physician boy i don't like that question um it is one that comes up app's are not scribe app's are billing providers if you look on your medicare carrier website you'll see many many have faqs around this where they talk about that the app um when being used as a scribe cannot independently make decisions cannot independently see the patient they would truly be acting as that living recorder of the physician in the room with the physician and only documenting exactly what the physician says to me that's a very high price scribe and definitely not at the scope of their licensure for that um do they are they used that way in some instances probably yes but you want to be sure you're meeting the guideline because that app can't go see that patient independently document independently and make decisions if they're acting as a scribe and it's also important to remember for split shared services split shared services are billed for hospital services so if you have outpatient hospital clinics split shared services apply uh incident two only applies to place of service office which is place of service 11. I think that's all of the questions that we have we definitely appreciate everyone just so you know we've had I think close to 700 people register for this webcast and most of the webinars that we have coming up and 621 of you attended today so we love seeing the great attendance and we appreciate everyone's support and thank you so much for attending today. Thank you. Thank you.

CPT coding

telehealth services

time ranges

evaluation and management services

coronary lithotripsy

loop recorders

telehealth requirements

ultrasound guidance codes

new technologies

place of service