Hi, everyone, and welcome to the webcast. We're going to give everyone just a bit to come into the meeting. Well, we're going to go ahead and get started with a couple of introductory slides as folks are joining the virtual meeting. Today we're going to talk about the proposed Medicare Physician Fee Schedule and the HOPPS Payment Rule. And this is for next year, 2024. I'm Nicole Knight, and I'm the Executive Vice President of Revenue Cycle Solutions and Care Transformation. And I'm joined by Linda Gates-Stribbe, who is also a consultant with MedAxiom, long-term member of MedAxiom. She is at Ascension St. Vincent's and is the Director of their Quality Department. James Varechchik, I never can get that right, James, every time I think I know how to say it. James is with the American College of Cardiology and the Director of Federal Regulatory Affairs. And then Matthew Manilla, who is also with the ACC and is the Associate Director of Medicare Payment Policy. So very happy to have you guys join us today as we go through the proposals. Just a couple of housekeeping items. On the Zoom control panel, if you want to type in questions as we go through the presentation, we'll answer those. And then also we'll answer some at the end. You should have some time. If not, we'll email you any answers and it'll also be posted on the Academy. The chat is only for the presentation. So there's a link there to a PDF of the presentation. So again, type all your questions in the Q&A icon. To claim your coding CEUs, you need to go to the MedAxiom Academy and claim your CEUs. And this is how you access your certificate. So this is where all your certificates are now housed if you're getting code or CEUs. So this webinar is approved for one AAPC CEU. So those will be available post-webinar. The objectives for today, we're going to talk about, as we said, the proposals for the Medicare Physician Fee Schedule and Ops. We're also going to go over some of the Quality Payment Program highlights and then some of the advocacy initiatives with the ACC. So I'm going to get us started. We're going to start with the Medicare Physician Fee Schedule. And we're going to go into, we're going to talk a little bit about some of the impacts first. So physicians will see a decrease overall in the conversion factor of 3.36, which equates to about $1.14. As far as cardiovascular services, really, it's going to remain flat compared to 23 this year with the changes in policies and services balancing out. As we talk about those increases, decreases, and things and it remaining flat, it's important to remember that the estimate is really based on the entire cardiology profession. And it does vary widely depending on the services that you provide within your practice or program. So just remember, when we talk about that it'll remain flat, you'll see some increases, some decreases, but overall should remain flat for cardiovascular services, where we're at now with the proposals for 24. So these are just a couple of informational things in the proposed rule. No surprise, they're kicking the can again on appropriate use. CMS is continuing efforts to identify a workable approach, which may be proposed in subsequent rulemaking, but they're continuing to pause that implementation of AUC at this time. So that was one. I don't think it's surprising us. I think we've postponed this a bit. So it's going to be a hard one to turn around, but it'll be interesting what a workable approach here will be in the future. This one is good news. So I have our little dancing man for split shared services. As you remember, in 23, there was a proposal that in 24, we would go to the substantive portion being defined by time only. Well, they have delayed this further, and we will continue to do the substantive portion based on either more than half the total time or on a choice of documenting the complete history, physical exam, or medical decision-making by the practitioners. So split shared services is proposed to stay the same in 24 based on that substantive portion of documenting history, physical exam, or medical decision-making, or more than half the time. So this was good news for many. Cardiac rehab supervision. I think this is another one that's good news. It's proposed that our advanced practice practitioners may supervise cardiac rehab, intensive cardiac rehab, and pulmonary rehab. These are proposed new regulations implementing those statutory changes that were backed by the ACC around improving access to rehab services. So this is another good news, and continuing to broaden that supervision requirement for advanced practitioners in our programs. Telehealth services. So just a couple of things on telehealth services, and I will encourage you to be sure to review, and we have a link at the back of the presentation as a resource, the most up-to-date CMS telehealth. As you know, when the PHE expired, there's varying dates, and there's different aspects to telehealth. As far as the proposed physician fee schedule, they are continuing to define direct supervision to permit the presence and immediate availability of a supervising practitioner through real-time audio and video through December 24 to avoid an abrupt transition at the end of this year. So that's one that I think is good if it continues to avoid that abrupt stopping it at the end of this year. They're proposing to extend audio and video direct supervision through next year. Also allowing teaching physicians to use that audio, video, real-time communications technology for those Medicare telehealth services in all residency training locations through the end of 24 as well. Telephone E&M codes, we're often asked about those. They will remain actively priced through 2024 is what's proposed under the flexibilities in the CAA. Additionally, CMS does not propose permanently adding cardiovascular and pulmonary rehab services to the approved Medicare telehealth list. This will not exist beyond 24 absent a change in statute. This is one I think that continues to be on the table but is something that they're not proposing for 24. I mean, I'm sorry, are not proposing to go beyond 2024. For place of service for 2024, telehealth services will be place of service 10, which is the patient's home at a non-facility rate or place of service 2, which is the telehealth facility rate. So you'll no longer be billing the place of service of your office or the location and you'll also no longer bill that modifier 95. Again, a lot of stuff on telehealth with different dates around the PHE and there's variables. So be sure to review the most up-to-date document there and we'll continue to keep you updated as well. One of the things to mention in the Medicare physician fee schedule is around remote device interrogation evaluations. So we have the G code, G2066, which is considered that technical portion for our remote monitoring of loop recorders or our congestive heart failure devices for the technical component or the download of that. They're proposing to delete that code, Medicare is, and assign the direct practice expense to the actual CPT codes, which are currently our professional component codes, the 93297 and 98. If this proposal is finalized, there will no longer be a G code. So the CPT codes, the 93297 and 98 will have both a technical and a professional component. There is no impact to the work RVUs of the CPT codes. Remember they're assigning that practice expense. So it's impacting the technical portion of the code. This could impact how you're billing for your services, depending on your contracts with your third party vendors or how you perform those within your office. So similar to many of our other CPT code services, you will, the G code will no longer be billed with the 93297 and 98 for our remote downloads of our loops or heart failure devices. Instead, you will either be billing globally, the CPT code, either split billing the TC and PC based on how you're currently providing those services within your program. There are some potential reimbursement impacts for these services with the conversion factor proposals. So this is one to continue to watch, particularly with your local Medicare carriers, as we get into next year. If this proposal goes through and what that fee is going to look like, and again, looking at how you provide these services in your clinic. Another area where there's some proposed value changes or some new values for the work or practice expense or around our venography services for congenital heart defects, our FFR for CT, our intravascular lithotripsy, intraoperative ultrasound, and our phrenic nerve stimulation system implants, removals and programming. So those are some to watch. And of course, we'll continue to watch those as we go as well. But there's some proposals for some changes to the values for these particular services. I'm going to turn it over now to Linda, and she is going to talk about other additions or proposals in the proposed physician fee schedule. Hi there. Can you hear me and see my screen? Yes, yes, Linda. All right. So you may remember when Medicare proposed that flat rate for E&M codes. That was back in 2019. And at that point, they had suggested two different complexity add-on codes that weren't quite represented by the codes themselves. That flat rate proposal went away because instead we had those new E&M guidelines for the office that came out based in 21, and then they were prohibited from considering that additional complexity payment by the CAA Act of 21. So now they're proposing to put that back in. So this would be something that adds on to our E&M codes. And it's intended to try to make up for the extra work that we do with the patient with multiple complex conditions and on specialists that have that longitudinal relationship with the patient. So primary care was named, but they also named cardiology, not here in this proposed rule, but in the original proposed rule in 2019 and who they were expecting to see it billed. Now before we get too excited about this, it's important to note that payment for this service, should it be finalized, it really accounts for almost a 1% decrease in the conversion factor. So should we get that dodge from the conversion factor, it is very likely that this will be the first thing to go. So we can't get too excited, but I think it's still nice to know that CMS does acknowledge that there is all that extra work going on behind the scenes that truly they feel is not really represented in just the E&M codes alone. It's kind of an acknowledgement of all that team-based care that we're rendering. Next slide, Nicole. So as we look at this next one, you know, they're proposing to do so many things, you know, and typically, well, I don't know, Mae, I'm probably wired a little differently than most people, but think about the movie, The Jerk. And you remember when the new phone books come out and Steve Martin goes, you know, jumping through the new phone books, that's me. When the proposed rule comes out, when the new CPT books come out, when the final rule comes out, that's me just because I'm excited about that stuff. But this year, you know, once you see the conversion factor and the fact that it's going down, almost everything else was positive for me. And I was like, you know, hey, what is this, some kind of new, kinder, gentler CMS? And truly, I think it's more along the lines of, hopefully, I know some of you are on the phone, but you can see the services on the right, and that's what we're going to talk about today. And just know that in addition to these four, there are others to help enhance and give us better access to some mental and behavioral health issues. Those of you that are in larger organizations that may have primary care and such as well, they're going to start covering, they're proposing to let people like marriage and family counselors apply for a Medicare provider number. They'll be able to do that as soon as it's finalized in the rule and start billing January 1. Same thing with mental health counselors. So you know, new categories of people for billable to help add those services. But look at everything on the left hand side. So they're under the list of initiatives mentioned. So you know, the executive order on increasing access to high quality care, patient-centered policies, strategic approach to address social determinants of health, changes in medical practice and team-based care, all of these different things, supporting CMS's new pillars of equity and inclusion and access and improved outcomes. All of these are different things that they mention as they talk about these proposals that we're going to walk through. So truly, you know, as they discuss these proposals and I'm reading this and it's like, you know what? These really sound like they want these things to go through. They're all acknowledgment of the things we do for our patients that truly isn't represented in E&M codes. Kind of those extra things behind the scenes. So I neglected to list those first two codes. So if you want to grab a pen, write these codes down. Oh, yes, I did list them. The 96202 and 96203, they're in the heading. Those are codes that were meant for a multifamily group setting to train people. And it did not include the patient. So traditionally, Medicare only pays for services that are rendered, you know, directly to or involve that patient. So when they came out, they did not cover those. So now they're saying, you know what? Having the person who's caring for the patient involved, understand, and working with that patient to help improve their outcomes makes a lot of sense. So yes, I think we should cover it. So even though they said they were not going to cover it last year, this year they're proposing to cover that. And not only that, but you see there, I've listed some X codes. That's what Medicare does when the codes themselves are not available yet. They kind of put the first and the last numbers, and then they fill an X in there. Well, those X codes include a 30-minute group session, and then 15 minutes. So look at what we're doing here. So they defined caregiver, that's a proposed definition, as someone that's an unpaid family member, friend, neighbor, guardian. That's working with a patient in a short-term or long-term capacity. So immediately, my mind goes to heart failure. And I think there's also some use, as we're looking at some of our bad patients, and maybe post-MIs, and our high cholesterol, where we really got to work on their diet and training and lipid clinics and stuff. So the patient doesn't have to attend. This would be something that you could do. Maybe we could have a class once a month, and people attend. So here, if you did the group, it would be billable per each patient who's representative. So let's say we had the spouse and a son or daughter. You wouldn't bill that twice, because they represent the same patient. So you would bill it once for each of the patients who are in that training session. And then that could be done as needed. And they're asking, and you see the last comment, one of the things they want us to comment on, is there a need to do this more than once in a year for a given situation? So let's say it was a heart failure clinic. Do we need to do this more than once? I'm thinking, yeah, maybe one for diet and others, and then others maybe for symptoms and or some exercises or some other things that we could do. But this I think is pretty darn exciting and has really good promise, so keep this in mind. Next one is community health integration. So when we talk about community health integration, here it's talking about, excuse me, certified or trained personnel. And this could be something that we're doing monthly if medically necessary, following an initiating visit. Now, it doesn't talk about what that initiation visit consists of and or if it's gonna have its own code. Now, traditionally Medicare has done that every now and then has given us a G code that says, okay, this is the initiating visit where I'm coming up with the treatment plan, I'm coming up with a plan, and this is the initiating visit. So it doesn't talk about that in the proposed rule. I think we'd watch for that in the final rule if this goes through, but it does say that you have to have that initiating visit first and the concept there is that the caregiver is, I'm sorry, the provider is defining what are the different social determinants of health that are impacting this patient? What makes it more difficult to get them to follow our treatment plans or put them at risk for failure or readmission? They want that to be identified by us as their practitioners. It will be 60 minutes in a month in order to be billable with an add-on code of 15 minutes. And it says, this is something we could contract with somebody to provide. So even though we would be the supervising or collaborating with whoever we might contract with, it does talk about that they want us to be pretty extensively involved. So it's not like we make a referral and then we just step out and let this other person do it. They want the clinicians to remain actively involved if they do contract for this, but they are opening the door for us to do that. This is something that if the patient is already on home health care, they're saying, okay, now that would be an exception. You couldn't do this both with the patient that's on home health and one who's not because they would expect this type of services to be rendered by that home health company. But yeah, it just goes through giving this long list to help patients understand, addressing those pieces. Almost each of these that we're gonna talk about reference the Z codes for social determinants of health. Now I'll show you on the last slide what some of those are, but it looks like what we're gonna need to do is what's key here is communicate what are the social determinants of health that we're looking at that's putting this patient at risk. So, and we think we see here by certified or trained XLA personnel. Well, that's left pretty undefined too. And we'll talk about that too. Next slide. So the social determinants of health, that's something we're already doing in most cases, most of the time. This would be an additional and optional standalone code. So when we are going through this, truly looking at this and saying, does this have an impact on our patient's conditions or their healthcare in general or the clinician's ability to diagnose them? They're saying this must be done on the same day as an E&M. So it's not something, when I say standalone, it's a standalone code. So maybe more correctly a stackable, one that will stack and be built in addition to an E&M on the same day. It is set, they do say they're proposing to add it to telehealth. So maybe somebody could call the patient in advance of the visit on the day of the visit because the idea is that the clinician needs to be aware that there is one of these social determinants of health that's been identified so they can take that into account in the patient's treatment plan. Each of these that I've been discussing, they put a lot of emphasis on patient centric. And that's what we're doing is really trying to customize what we're doing to that particular condition and that patient's condition. So it does need to be done on the same day as a visit. There's some discussion on should they include the annual wellness visit as one of those qualifying visits and when that can be done. And if so, yes, they can, it would still be billable. What they're saying is they're proposing that it would be a lot like the advanced care planning. So advanced care planning right now, there's no patient out of pocket or co-pay when it's done at the same time as their annual wellness visit. It doesn't mean you can't do it on any other visit. It just means there's no patient co-pay. And we're gonna actually have a webcast in the future about advanced care planning. So stay tuned and watch that. It does talk about that you must use a standardized tool. It lists sample tools and you can see those there on the right. So if you're doing this already in your practices, look at the nature of the questions, make sure they conform to one of these tools. That's gonna open your options of billing this as a standalone. Now in the proposed rule, you can see they're saying the code's gonna be one of those G codes and they described, they crosswalked it to the same reimbursement that they do like for the depression screener right now. So it's not a lot of money, but I mean, it is extra. And with extra focus, maybe we can take more time and do a better job of identifying these. And again, we'll need those Z codes. Next slide. So principal illness navigation. I think this one is so right for us. So if you think about principal illness navigation, they're talking about conditions that require a high risk disease that they think is gonna last three months or more, something that puts the patient at risk for acute excerbation or requiring monitoring and revision of care plans, frequent adjustments. You can see the list there on the second bullet, but it names heart failure as one. This could be furnished monthly. Like the others, it needs that initiating visit. And of course they didn't name a code, but like all the others, they say that hospital, observations, ED, nursing home, none of those would qualify. So they're looking for a clinic-based service, 60 minutes a month, and then an add-on code. So here again, we can contract with other people. So you're seeing this theme. There's definitely an encouragement to actually help us find a way to do these things if we aren't already. And if we are, an acknowledgement that this is time and resources and impacts the patient's condition. I mean, this really can make a difference. Now they do hold out, we have principal care management, PCM, right now that's been around for years. And it says that the conditions and the services that we would provide would likely be very similar, except that they expect these to be a little more focused on social determinants of health as one of those extenuating factors. So you just see that repeated theme over and over and over. Next slide. So here, what you see on the left, this is what they give us as who can provide the services. I mean, a lot of people are thinking, okay, so can my MA do this? Is it an LPN? Is it an MPP? Well, it's definitely not an MPP. It could definitely be lower trained than that. These are what you see on the left are all the various comments that it gives. And it does say, you know, absent state law that says otherwise, as long as they're trained and certified. And it does talk about people like the community health workers and social workers, lots of folks, not necessarily at the highest level. So really look at some of that and some of the descriptions also in the proposed rule, it goes through the list of services in a bullet format on what they think these might entail. So you really could just look at some of this in the proposed rule, look at the nature of the services being rendered, and you're probably already doing it and unable to bill at this point. So on the Z codes, this is just a small listing of some of them, but you can see them. And as we know, these do impact our patients. So we'd have to be familiar with these and add them to the services when rendered. Next slide. Just a quick comment here about advanced care planning. Like I mentioned, we are gonna cover this in a work group. This was up for review. They maintained their current CPT. That's the long and short of it. But keep in mind that this is not to be rendered only by primary care, but anyone who's, you know, the patient's condition is medically necessary and warrants having that discussion. All right, exciting stuff. James, I'll turn it over to you. Thanks, Linda. And then we can go straight to the next slide, please. I'm gonna just go through a few high level things in the QPP program. I'm gonna couch this with, I am not the best expert at ACC on this, but I raised my hand to try to relay some other folks' fine work here to get an overview. And if you have questions, you can put them in the chat and we will be aggregating them and we'll be able to try to get back to you after this presentation. But the things just to run through here briefly, you know, additions and removals of measures. There's about 200 measures in the program, or maybe even exactly 200. And you can see listed here some of the specific additions that are relevant to cardiovascular space. And then also there's one topped out measure proposed for deletion. I think they even called it extremely topped out. So y'all must be very good at this. And we can go to the next slide. Broader in the MIPS space, there are some additional measures that will be relevant to the heart disease MVP. And those are listed out here for you to see. There are five other MVPs proposed that are not cardiovascular. Things like head and neck illness and disease and stuff like that, that we don't have to worry about here. We'll also note here that overall the MIPS threshold is increasing from 75 points to 82. That probably means it will be a little bit harder to avoid a penalty, and that potentially some penalties could be a little bit larger given the way the program is built, but that's the number you have to shoot for. And then we included here the components for your MIPS score. On the next slide, we can go through a few changes in the MSSP space. That were related to ACOs and adding a track that allows for both greater risk and greater reward here in the third part there. And I think the other changes were related to the way that they're using certified EHR technology and trying to align that and update it across several different programs in a nutshell. That's a lot of text right there. I know that everyone has these slides afterward, and we do have some links at the end of the presentation here with links to some fact sheets and other information. If this is new to you and you want to dig in further, we've got that there, and you can also reach out in the Q&A or via email afterward. And I think that might be all you need from me, Nicole. Great. Thanks, James. And we can go to the next slide to go over the OPPS. Okay. So not a whole lot cardiovascular related in the OPPS proposed rule this year, but a few highlights. The overall system is going to be going up 2.8%, which is a 3% hospital market basket update reduced by the 0.2% productivity adjustment. One of the more notable things to us that we realized when the rule came out was that there was actually not the addition of cardiac ablation services or proposed addition to the ASC CPLs covered procedure list. There was a lot of speculation that this would be, or at least addressed in some manner. So little surprising that it was A, not proposed, but then B, not even really discussed, despite our knowledge that there were several pushes to get that in there by different stakeholders. Some normal movements within the APC rates and assignments. One notable one that we are working on comments for is the PET CT scans. There's three codes that are affected in that group, but the largest one by volume by far is the first one, the 78431. The way we have it written there, going back to where it was two to four years ago, it's a little bit confusing. These codes all came into existence in 2020, and they were in one APC group, 1522, from 2020 through 2022. And then based on the data from 2022 and 2023, we're bumped up to a higher paying APC. And then based on the data this year, it's proposed to move them back down. So we are working on that. We're working with ASNC on aligning our comments regarding that. No changes of note to cardiovascular services on the inpatient only list. Also no changes to the cardiovascular codes in the ASC covered procedure list. There's an RFI request for information regarding the packaging of the radiopharmaceuticals. This would again touch on the nuclear cardiology. I guess there were comments received from CMS both this year and in past years pushing that certain radiopharmaceuticals should be allowed to continue to have separate payment even after their pass-through payment period had ended. CMS is basically saying, you know, to pay for everything separately is antithetical to the prospective payment system, but they don't wanna inhibit access to Medicare recipients of these radiopharmaceuticals. So they're asking for anybody's idea of maybe some middle ground. There's an addition of 230 dental codes to clinical APCs in this rule, as well as enhanced enforcement of the hospital transparency requirements. Basically just saying there's rules that were already on the books. They're not being followed. So they're gonna try and really step up cracking down on that on the hospitals. That's it on the OPPS. We can go to the next slide to get to some advocacy highlights overall. And James, you'll start this off, I think, with PPIS as your- Yeah, I'll go through a few of these and you can close out the one at the end, I think not. So yeah, I wanna note to this group, I know that this group is highly paying attention to practice cost topics. So I'm really glad that today we'll be able to be on the program here. The AMA is doing additional PPI survey to gather indirect practice expense costs, overhead and administrative staffing, rent and utilities, all those sorts of things. We've been trying to talk about it a lot through MedAxium and ACC so that people are aware of it because it's not actually an exercise that we're doing. We're just trying to raise awareness of it on behalf of the AMA and the contractor they've selected for this Mathematica. One of the links of the additional links page here at the end we'll have, and you all can get from the link in the chat, is more information about the PPIS. So if you get one of those, I've seen the tool. It's challenging. It's not an easy sit down thing to do in five minutes. And it's gonna require people working with financial data and looking across multiple years to try to get a sense of things. So it's pretty involved, but it's extremely important. So we do want people to try to do that and work through the challenge of it. You know, Nicole led off with the change in the conversion factor. We finally have some movement with this in Congress because that's where we actually can try to get some satisfaction here to remedy this. CMS is implementing the law when they're saying the conversion factor is X because we have an increase in services and we have to keep everything roughly budget neutral. So this bill that's referenced here that ACC supports and is really pleased to be behind with a lot of other people in medicine would add an inflationary factor to the fee schedule, just the way that the other payment systems have where the fee schedule does not. So I wanted to note that here. That's one of a couple of ways that we're trying to work with the entire House of Medicine to get this problem addressed. Of course, the problem is it's expensive and everybody knows how generous Congress has been lately. So we will see what happens with that. Legislative conference is coming if you haven't been or if you've been before and you're a regular, look forward to seeing you there. Wanna note that here though. Some other, I'll skip to carotid artery stenting. Maybe you saw, if you pay attention to peripheral vascular topics that Medicare is looking at an updated coverage policy for carotid stent indications for Medicare patients to broaden that. And so the comment period on that just closed. We had a little news item about it in our advocate newsletter. Also in the coverage space, that T-set is transitional coverage for emerging technology. It's the agency looking for ways to get new and exciting technologies covered more rapidly when they come out of the FDA's breakthrough technology process. There's been some fits and starts on that in recent years about a way to do that, and what their proposal now is actually, you know, it's a way to shave off some time. It still requires a process and some review if you're familiar with the national coverage determination steps, but it does seem to be an improvement and still allows some back and forth there. Right now, the CMMI had put out an RFI to try to gain information about specialty care and specialty-based models for episode, different ways to do episode models, so we're working through getting some comments on that, something that you might see. And Matt, you wanted to touch on restrictive covenants here, so I will let you do that. Thanks, Jim. Yeah, a couple items, a couple notes regarding restrictive covenants. So, last year, our ACC Board of Governors subgroup worked to put together a white paper on the topic, and that was just recently released in the Jack Advances Journal. Either was or will be in the next issue. The bigger news on that is that early in this year, the Federal Trade Commission released a proposed rule that would propose to label all non-compete clauses in employment contracts to be an unfair method of competition, with some very narrow exceptions for the sale of a business. And, you know, we made comment on that in collaboration with a lot of other folks. As many medical societies did, it was a somewhat nuanced comment, but I think the stance was overall in favor. You know, the majority of cardiologists these days are employed and do not like to be under restrictive covenants or especially non-compete clauses. So, we don't, you know, the comment period on that has closed several, I think in April, it closed after an extension. So, we don't know when the final rule is going to come out, but it's a major topic of discussion, obviously. There's a lot of questions. The biggest question, I think, out there to be settled yet, besides whether they're going to finalize this rule or not, is whether or not the FTC has jurisdiction over non-profit hospitals or health systems. That's a big question because even if this were to come out, if it only applied to for-profit, then that would leave many, many, many physicians working at not-for-profit hospitals and health systems, you know, still being able to be put under those restrictions. And we've heard from lawyers in all different walks of the, you know, life that have had different opinions. So, nobody's really sure. The one thing we're all pretty sure about is that whatever happens or whatever is declared, there will be lawsuits in every direction on this for many years to come. And final note on that is that there is, while this is being, you know, we're waiting on how this turns out at the federal level, many states already have restrictions on this. Many states, they are not enforceable, but there's not restrictions saying you can't still have people sign them. And there are states that are continuing to try and get laws banning these restrictive covenants or non-compete clauses on their books. Recently, New York state got one passed through the state legislature. And last I heard, they were waiting on the governor's signature for that. And so, a lot of the state chapters are working on those programs and the ACC, Maine ACC does help out our state. We have a separate state legislative team that helps with those efforts. That's it on restrictive covenant. And Nicole's showing here a bunch of different links that I sure hope stay live in the PDF version of this. But our summary, the rules, the rule itself, the QPP site, the fact sheet from the QPP program is lengthy in detail. We also include ACC's grassroots page. If any of you want to contact your Congress people to tell them to support that bill I mentioned, and even the restrictive covenants white paper that really just got posted a week or two ago, I think. So, there you go. Maybe next is Q&A. Yes. Thanks, James. Just a couple of other little reminders here. So, the Medaxium Fall Meeting, the CV Transform is in Austin, Texas. It's October 5th through the 7th. So, be sure if you haven't registered for that, always a nice time. James talked about the legislative conference. And then we also have an EP webinar. Linda, do you want to chime in on that EP webinar just to give them a snippet of what that's geared towards? Sure. I'm excited about this one. Of course, I get excited pretty easily on this stuff anyway. But this is geared towards your EP physicians. So, I've never seen anything work so quickly in a revenue recovery than put a bunch of EP doctors in a room for 45 minutes. When we go over these bill of the coding and billing guidelines for ablations and procedures, I tell you, nine times out of 10, they will stay afterwards, talk through their, what are we going to do differently as a result? How are we going to improve? And whatever issue you might have had in the revenue cycle is fixed next day in the lab. So, really encourage some of your EP doctors, the more the merrier, to join on this. This is geared for physicians. Coders always welcomed. But geared for physicians. So, get the word out. Thanks. Thanks, Linda. Yeah, this is geared towards physicians. There won't be any coding CEUs, just as an FYI. And we're also doing it at 5 p.m. Eastern to hopefully appeal to some of that physician time as well. The calculator, James mentioned that. It's available and can be downloaded. And then also, Linda and I are doing a HeartTalk podcast series around revenue recovery. There's been two so far. And we're continuing to post some of those. So, Linda's been great at the podcast. She's going to be our next podcast expert. We're going to try to make us go viral here around the revenue recovery. So, please tune in for that as well. So, questions. So, I know we answered a few. Just a couple of clarifying things. So, appropriate use criteria, and I apologize, is around only advanced imaging services. So, I know someone had asked a question about that. James, I know rehab is a very popular topic, and we answered a few questions around that. So, any comments overall on what's happening around rehab? I know we have several extensions through December 31st, 24. Was there anything that you'd like to add around that with rehab, since we have a lot of questions around that? Yeah, and I did put that in the chat. Everyone's able to see that, I believe. But a couple folks had asked some pretty specific questions. And Nicole, you can help correct me along the way here. But I think, unfortunately, we've kind of got several different ways to answer these, which I hinted at. So, one is that, first of all, implementing the law that was passed five years ago is happening. So, that means that APPs can supervise now. And so, that will address some things from pre-pandemic and beyond that, you know, might just streamline things in general. Second is, part of the bill that passed last winter was to extend a lot of the flexibilities through 2024. So, that includes the way that the agency applied this virtual direct supervision, is how I've called it. I just put it in the chat. They say direct supervision via 2AAV. So, you can, the supervision can happen virtually through 2024. The third thing is, it's different if you're talking about the facility technical fee. I think that's, okay, I'm glad you're smiling because I was like, I think that's what we researched, right, Nicole? The hospital without walls ended May 11th. So, you know, doing that, billing the facility fee in the OPPS system for a patient in their home is off, in a nutshell, is how I've interpreted that and the way that we talked about it in our kind of COVID transition page, which I now see, well, I guess those don't need to be updated just yet because these proposals haven't been finalized. Some of those would change things on that page I put in the Q&A based on the rule making of the agency after November 11th. Is that helpful, Nicole? Yes, very. Thanks for the clarification. And Linda, lastly, I know it's interesting because I saw someone posted a question about, you know, we have chronic care management, we have principal care management, now we have social determinants. And I feel the same way. It's like, which one path do we go down and how can we document best and are we opening ourselves up, you know, for scrutiny? What would you comment on that when you're evaluating these services, particularly in cardiovascular, Linda, and how folks should look at them and what are some opportunities? The way I look at it, I guess a couple of different ways. And I would absolutely agree that we're really going to look at the nature of services being rendered and the nature of the patient's needs. Now, through each of those initiatives, there is significant emphasis placed on social determinants of health. So I think, you know, even as one of the slides I pointed out that Medicare said these are the same conditions, very similar in the nature of things, but they would expect the principal illness to focus more on what are the social challenges unique to that. So the person who's going to truly get them in touch with housing or whatever, I think of some of those community health integration, the caregiver education and training. That one, I think, you know, I think about so many programs that we wanted to do with nutritionists and that type of thing. I think the biggest thing that jumps out at me, I mean, I remember back in the day, you know, 25 years ago, we would take a class to the grocery store, and they would walk with our nurse through the grocery store and they would show them how to read the backs of labels and then end with recipes. And, you know, we could do something like that. And that would be a caregiver training geared towards our patients with hyperlipidemia so that the spouse knows how to cook. I mean, I think, you know, it's time to put our thinking caps on. And yes, there's some overlap, but some of those other things to require the patient to be sicker than maybe some of these others. So I think just really look at those elements. It does lay out the nature of services, kind of bullets, each of those under a section there. I gave you the page numbers. I know it's not a lot of fun for most people to read the final rule, but it does give you what they're expecting with each of those services. So take a look at that, see how that compares to what you're doing, and if one of these would be complementary. It doesn't say anything about precluding it as you read through these. Same, definitely the social determinants of health, that absolutely can be billed instead. Only thing it talks about is not in conjunction with home health. So yeah, I think it's time to think about what are we doing, what would we like to do if we maybe could have some revenue from it, and give it some thought between now and the end, and know that things look pretty good for 24. Awesome, thank you. And the final rule is expected to post, I believe, by November 2nd. So we'll all stay tuned for that. Linda will be reading through those 5,000 pages within minutes. I think she's a speed reader, but we appreciate everyone attending. Any other questions that y'all think we need to address? I was looking at the ones that just came in. There's another one about the caregiver training and CV rehab, and I don't know if that's one that you can answer, Linda. Yeah, we might have to dig into that. A different one about the diagnosis code for a certain CPT code. I can't answer that one on the fly here, but maybe we can dig into that too. I had a question if I could for Linda, though. I was curious, you know, we've been grappling with this, and maybe it's instructive, you know, put it in the Q&A. It's kind of your vote, audience, but we've been trying to parse through, like, the impact of the G-22-11 code. You know, the financials is, like, roughly net neutral for cardiology, so it's kind of like, how impactful is it? And then it has this negative impact on the conversion factor. You know, the longstanding kind of critiques about it maybe not being terribly clear, well-written, like, does it apply to basically everything? You know, you seem to tout maybe some of the positives about it as there be under-recognized work that remains even after the E&M accounts. Is that kind of your take on it, Linda? It is, and if you read through Medicare's comments, you know, they're acknowledging truly that the caregiver approach and the whole patient-centered approach and care team that we're doing, they act like it's newer now than it was 20 years ago. I'm not so sure it's new, but it's certainly advanced and getting more important. And, you know, when we add people like population health and, you know, some of the prompts now with electronic medical records and quality metrics, you know, we're able to better address some things. So, you know, to the point of providers on a WorkRVU-based contract, you know, if it's WorkRVU, their WorkRVUs go up, their contract reimbursement can go up, even though administratively, the reimbursement may go down. So, you know, you've got the admin, not so much, clinicians, heck yeah, you know, we would like to get more credit for all this extra time that we're putting in before and after and in all this care planning. And that truly seems to be the nature of it. They talk about, you know, it wouldn't be billable along with, you know, any type of procedure on the same day or by people who have a short-term relationship with the patient. They talk about a lot of surgical type things, but then it does name endocrinology, pulmonology, cardiology, you know, a lot of specialties who just due to the nature of their patient population, do have maybe a little arguably more extensive interaction and expenses as a result. So, yeah, in a perfect world, I love to see both happen. Dodge the conversion factor and get that. See what you can do about that. Yeah, we'll work on that. See, I had always wondered, like, it just sounds like that's a really solid level five E&M, but maybe it's more than that. I don't know. Well, I had a doctor, as we were talking about the prolonged services, which is something I think, Nicole, we're going to cover at the conference in fall, had a doc call and say, are you sure there's no such thing as a level six? I was like, actually there is. If you meet the requirements for prolonged. So I think that's what this would be, you know, like, give me that extra miss, you know, Miss Betty Sue's not like Mr. Frank. She's, I would build both of them a level four, but man, we put so much resources into her because of all these extenuating circumstances. So I don't meet prolonged attendance, but they're not equal. And I think that's what Medicare is trying to say too. And they estimated it would build like, I think 38% of the time. So they're not saying everyone, but I still fingers crossed for both. So what are you going to tell your interventional cardiologists? Well, you know, they need the same type of prolonged care and the training for EP docs, interventional cardiologists do the same thing. I don't know if it's just the nature of the way their minds work, that they see it, they fix it, see it, fix it. You know, having a session, you let them know, these are the things that we could do. And by doing this, we can, we can better things here. We can add things there and increase revenue and work RVUs. They're all on, they're all in, you know, I think interventionalists, let's think about what we do to post MI patients, post TAVI, post TAVR. How do we take advantage of some of the caregiver or principal illness that might be tailored to that patient population that would deserve at least one session? I think there's some good stuff. Yeah. I think the key is, is that if you're the, if you have patients and the, you know, templates that are every 10 minutes, which we do see those, it's going to be pretty hard to do any type of these services. But if you do have those patients for prolonged care and those types of things, as we're talking about that, you are spending the 45 minutes or longer with patients and having some, you know, we've now got dieticians and social workers and all this support within our clinics. And I think looking at those resources and how they can help our patients may not all be around those physician time. I think it's important to look at those other services that we talked about for sure. Well, and Nicole, I guess I would add the question specific about caregiver and cardiac rehab. I think, you know, if you're an exercise physiologist or someone that's overseeing cardiac rehab, the question was, was it billable under that or only at bedside? It does not give us anything so far as parameters there, except that the clinical parameters of the patient. So I, I think you could probably talk about doing some, how to exercise safely on patients, not undergoing cardiac rehab, but may need, you know, some suggestions. And I, I think we got a lot of possibility here. Great. It's always good to end with great optimism for sure. So, well, thank you so much for joining all of the speakers today and being a part of this webcast and thanks for everyone's participation. We look forward to seeing you on our other events. So everyone have a good afternoon. Thank you very much. Thank you.

Medicare Physician Fee Schedule

Hospital Outpatient Prospective Payment System

2024

telehealth

caregiver training

social determinants of health

advanced imaging services

restrictive covenants

billing cardiac rehab services