Hi, everyone. We'll get started shortly. We're going to give everyone a chance to get logged in. It's so nice to see those numbers go up when you turn it on, right, Linda? It is. It jumped fast. Wow. We're almost at 400. Welcome, everyone. All right, well, I'm gonna go ahead and get started with some of our housekeeping. My name's Nicole Knight, and I lead our Revenue Cycle Division at Medi-Axiom and work for the Care Transformation Team. And I'm joined by Linda Gage-Stribbe, who is a consultant for Medi-Axiom and also works in the Ascension System, still in Indy. Many of you know Linda. So Linda, are you able to hear me okay? I am, thank you. Can you hear me? Yes, absolutely. All right. All right. So let's go through a couple of housekeeping slides. The first one, the FAQ or the QA button, you can ask questions throughout the presentation and the entire Revenue Cycle Team, and Linda and I will be monitoring that box and we'll answer your questions throughout the presentation. If we have time for questions at the end, we'll take a few questions. Any other questions we will answer after the webinar. Also, the handout is available in the chat link. You can download that PDF version and you can save it or print it. It is available there for download. Also, your CEUs can be claimed in the Academy. Just a reminder that everyone has to individually register in order to claim their CEUs. I know I saw on some of our bootcamp feedback that there should be an easier way to register, claim CEUs and all of those things. I think it's important to note that the AAPC and even AHIMA has really started with extensive requirements on being a CEU vendor and what that registration looks like. I will tell you, we do CMEs for physicians and clinical folks as well. And I think our organizations of coding have gotten just as particular. So a lot of those things we don't have control over. So you do have to individually register and attend the webinar in order to claim your CEU credits. This webinar is worth one and a half CEUs and you should have your credits available to you this week and before the holidays. All right, so a few session objectives. We're gonna do a brief recap of the 21 and 23 guidelines, touch on a couple of those problem areas. We're gonna discuss split shared services in the hospital, go into some critical care. So are you up to date on the latest guidelines? Are there opportunities around prolonged services? And then we're gonna talk about the CMS add-on visit complexity, the G-code, what we need to know as we go into 24 and what are folks doing in that space. Linda, I know you wanted to chime in on these couple of slides with a story and I think that's always the great way to kick us off. So turn it over to you. Great, thank you, Nicole. Yeah, just a quick word that it's easy for us as coders to get focused on content specific to coding needs but as you can see in that little circle there on the left, I mean, the medical record first and foremost is that care team communication and making sure that we meet all of those. So we may focus on things to say and not say from a billing perspective but we can't let that number one and all those other uses ever get too far away. Now, with that in mind, I wanna share with you one of my favorite notes. So as you will see, this is a note from 97. Back in the day, some of us are dinosaurs. When physicians hand wrote their notes and we had to try to figure out what they're saying, I met this particular group of physicians when their attorney called me and said, hey, I need you to do kind of a drop everything audit for me. And I'm like, okay, what's going on? He says, well, I have a group that had to sign a corporate integrity agreement with the OIG or the Office of Inspector General. They were supposed to have done an annual audit and they haven't done it yet and the OIG wants to know where it is. And I'm like, oh, okay, well, sure, I'll squeeze it in. So I get this big box of notes, open it up and this was the first note. Now, let's read it all together, shall we? I think we can all figure out the first part. No chest pain, mild dyspnea. That would be off and on as before. No edema, brief flutter, off and on as before. No dizziness, lightheadedness. What's that next line? That would be sleep, appetite, bowels and urine. Check, check, check, yep. This note in its entirety is the entire documentation to support a level five consult. I called their attorney and said, you know what? This is not going to go well. So he said, well, it is what it is. So I like this. I know it's out of date. I know we don't use handwritten, but our docs do free text. And so it's just a good reminder to use standard abbreviations, you know, as we look specifically at some of the government auditors and stuff, if they have to read too far into your life, I mean, a lot of them have little teeny tiny imaginations. You really need to just spell it out. So I like this for that reminder. And I also like it as a reminder to our clinicians that say, you know, you may hear some rules here today and say, gosh, I don't think I've been doing that. Well, that's okay. You know, you fix it. You fix it, you go forward, you tweak it, you fine tune it. I bet your mistakes aren't as big as this. And they kept their Medicare license. So with that, I'll turn it back over to Nicole. Thank you, Linda. All right, so let's dive into some of the 21 guidelines and a recap of some of the key concepts. And this is focused mainly on our office and outpatient services. So in 21, that's when they moved to medical decision-making or time. And we got a revision to our table of risk and it's our medical decision-making table now. Really focused on definitions around the key elements to understand around the problems, around external unique or independent reviewer discussion, the level of risk, those types of things. And then in our time-based billing, where we used to have to be 50% or more of the visit was based on counseling or coordination of care. And we used to use that statement. They talked about what's included, what's not, whose time can be included, what needs to be documented. And also, do you spend time creating that note and documenting that note in your EHR and that you can count that time. So lots of changes in 21 that have kind of led us to where we are today. So basic expectations for documentations. Again, I think this is a reminder when you look at that note from Linda, you know, we don't have handwritten notes nearly as much. I won't say they've totally gone away because occasionally I'll see one pop up, but I think it's important just to remember what are those basic expectations for documentation, not only from billing purposes, but also when you look at this note from a medical liability perspective and what's needed. So chief complaint, even though we know the history and the exam are not the services that determine the level of service, we still need a chief complaint or a reason for that visit to support the medical necessity. Timeliness, often asked, what is truly the black and white guideline on how soon the provider needs to sign their notes? Well, this is the exact language, as soon as practical. There's really no days, no timeline, but as soon as practical. So what does that mean? Well, 90 days, wouldn't say that's practical. Most places we go, 30 days isn't practical. So that timeliness of completing and signing that note, the legible signature, we know that a lot of it is not signed anymore manually. So what does your electronic signature look like? And the rationale for ordering any diagnostic texts, the progress response to treatment and any planned instruction. So just those basics as you're looking at your notes. New or established patients. So that new patient definition, and oftentimes we're asked about this from a CPT perspective or CMS perspective and other payers, because there's one thing to remember, pay reimbursement may vary when you look at this definition of new or an established patient. An individual who has not received any professional service from a provider of the same specialty who belongs to the same group practice within the previous three years is a new patient. And an established one, of course, is one that has received the service. There's no distinction between partners in the same specialty, meaning if you're all cardiologists and that's your primary specialty, then you're considered one in the same if you're within that same group. However, when you look at this and you look at the subspecialization in cardiovascular services around advanced heart failure, EP or interventionalists, if that medical necessity supports that both providers see that patient the same day, they are billable by separate specialties. Now that doesn't mean they're gonna be paid. So I think your payer reimbursement does vary, but ultimately EP, advanced heart failure, interventionalists are all separate specialties under CMS. And if you're within the same group and you're truly seeing them and it supports that reason for the visit, then it is a billable service. The next two slides are around our medical decision-making table and how did that change? So when we look at this, the key here that you'll hear Linda and I talk through is it still comes down to, in order to reach medical decision-making, you have to meet two out of three components. Those three components are the number and complexity of problems addressed, the amount of data and the risk. The items in red are what was changed or updated in 21. And we also added a column to what codes relate to that and then the level of medical decision-making. But when you're looking for those two out of three, it's those three primary areas that you're looking for, where does the service meet that? Moderate is generally where cardiologists peak. And then if you go to the next slide, Jamie, this is, it represents high. So we're gonna talk about a couple of these definitions and what has been some of the clarifying and tenacious points that we look at on a daily basis. So the key here is we get to know our doctors very well as you code and audit for the same physicians. And when you do that, oftentimes, you're looking for what's documented. We can't assume or fit one thing into a particular category. So how often are we asked, can you tell us what always meets a five? You can't always do that because it's two out of three. So even if they meet it on high risk, they have to meet it either on data or the conditions. So comments on just some selected definitions. So Linda did a good job of putting together the slides and it has the exact definition. I think a couple of points to comment on around this is when you talk about that external source, you wanna mention any note you review from outside of your practice. Two supports data for level three when you're looking at amount of data. And if you're looking at three, it supports data for level four. Now, remember, you have to meet other data elements, but for that external source, the key here is any notes you review from the outside of your practice. However, you do have to document that in your note. Around independent interpretation of tests, a reminder, if you perform labs within your clinic and you bill for those labs, same thing with an EKG, you don't get credit for that independent interpretation if you ordered and billed, you do get credit for the order. And unique refers to what can be billed by CPT code. When you look at problems address, the need to say something beyond the issue being followed or referred to another is what you need to do for problems addressed. So these are just some common tips around that. What that is, is if you're addressing their diabetes as part of your medical decision-making, as an example, if you just say treated by primary care, that doesn't necessarily support that you address the problem. However, if you say diabetes patient on insulin, A1C is stable, managed by PCP, problem is addressed in that statement. Doesn't have to be a lot of words, but it does have to be in the documentation. These next few slides go through the additional definitions around the complexity defined. From this one, I'll call out, just because we want to be sure to get through all of our topics. I think where this is highlighted in the middle, when you look at a stable chronic illness, having that statement in there in that last sentence, a patient that is not at their treatment goal is not stable. I think that's crucial when your physicians are looking at what that looks like. So if they're stable today and they're seeing the physician, but they're not at their treatment goal and that's exam and it's documented, then that doesn't necessarily mean they're stable. So what does that look like as you go from a low level three to a moderate level? This is around the moderate level. So when you look at moderate, we have one or more chronic illnesses with exacerbation or progression. So looking at that definition and understanding, are they having side effects? Is their condition progressing? Two or more stable chronic illnesses, I think that's the one that we usually all fall in, particularly in the office or outpatient setting. And then when you looked at those undiagnosed new problems, is there something that the patient has? Is there acute illness with systemic symptoms? What does that look like in our world? And how is that supported in the problems addressed and the conditions managed? For our high level, when you look at, this is our four levels, and you look at the risk of those four levels, you can see why we moderate and high are generally where we see cardiovascular services. So when you're looking at moderate and they have a new diagnosis or treatment, and this is a reminder, and they're getting prescription drug management. Now, what does that mean? They're not just checking the box that their meds were verified. They're continuing a medication. They may be refilling a medication, adjusting doses. But also, Linda calls out the social determinant factors which we'll have a little slide on further down. Remember, that also comes into that moderate level. Level five, that drug therapy requiring intensive monitoring is now defined. Also, if they're considering hospitalization, not just sending them to the hospital, but if they're considering it. And then if they're deescalating care, all of those things may represent high risk. But again, you have to meet also either the data or the problems addressed. So a few complexity reminders. Only listing the conditions, meaning only bringing over your problem list of comorbidities conditions, are not considered in selecting the level. So you do have to address those conditions. And if you think about MEAT for a risk adjustment, addressing, documenting, and supporting that medical decision-making, and then also using that MEAT to get to your risk adjustment, to your more specified diagnoses. The final diagnosis in and of itself doesn't determine the complexity, it's the extensiveness of the evaluation. Now that is where you are in it has to be documented. We can't assume it has to be documented within that note. It should be consistent with likely the nature of the condition. And the MDM table is, from a CMS perspective, this is a guide to assist. Not everything is going to be in that table and you're not going to be able to fit everything into a category. It does take some understanding of that patient's condition, treatment, and what's going to be happening to that patient in that moment in time when the provider is seeing that patient. This is the social determinants slide. I know we went over it too when we talked about the changes around some of the social determinant codes. I think Medicare has some great information and this is from the AAFP and it goes through those different conditions. And I don't think we always think about this in cardiology, so it's definitely a good reminder. Reminders for high-level medical decision-making. So when we look at data going from moderate to high, so that column to the amount and complexity of data, you need two out of three. So you will need three in Category 1 in order to meet Category 1, and then you need either Category 2 or Category 3. So if you didn't do an independent interp or discussion with another clinician, you won't qualify for Category 2. And then you can also just use Category 2 and 3, so you don't have to meet one. It can be any two or three of these categories. But again, you have to be sure that you're meeting two of them in order to be high. For the number and complexity of problems addressed, chronic illnesses with severe exacerbation, I think we need to pay attention to these definitions. I would share them with your providers. And really, does the documentation paint the picture for that complexity of those problems addressed and what they're doing? Does it show that the patient has a severe exacerbation or progression? That they have significant risk of morbidity if they do not get the treatment that they need or they're having side effects of that treatment that may require that hospitalization level of care? And I think our acute illnesses that oppose a life-threatening emergency, those types of things, we're pretty good about looking at those acute illnesses, such as our AMIs and pulmonary embolism, severe respiratory distress. But I think sometimes when we're looking at that first one with our chronic illnesses, do we have the documentation to support those severe exacerbation, progression, or those side effects of treatment? So some of the sticking points. Is it from your office for the internal and external note? Is it in your organization? If it is, remember, definition, does it meet that? Is it your note or an interpretation of your note? Is it copy-paste? All things to think about when you're counting that. Prescription drug management. What specifically did you need to document? There are some payers who specifically have what you need to document from a Medicare carrier perspective. You wanna be sure that you're looking at those FAQs. Are you just checking a box? Remember, checking a box doesn't work for refilling it, just checking a box. Do you have a blanket statement, continue all meds for all the conditions listed? What does that give us on that? So again, are you giving us what medication you're managing? What is it related to? Only has to be one. So what does that look like? Intensive drug therapy for monitoring. The documentation of that specific risk of that drug therapy. How are you monitoring it? And remember, drug therapy for intensive monitoring, I often hear for high level five services or level three rounding visits. Well, they're on a drug that requires intensive monitoring. That's only one element of the medical decision-making. Remember, you have to meet one of the other components on their condition for that day or their data and the data reviewed. So just a reminder that even if they're on an intensive drug therapy requiring monitoring, they're documenting that every day depending on what their condition is that day and what data that's gonna also matter in the hospital setting. All right, and just to sum up our changes as we go into it, our time thresholds for our office and outpatient visits are aligned in a format. And on the next slide, we'll show you that. Also, you wanna check to see if you need to update any of your text macros or dot phrases if you've been using certain time ranges or if you're using terms of greater than and things like that. You wanna be sure you're documenting the exact time to exceed the time or to either meet that time. And then how will this impact our office-based prolonged service codes? So Linda's gonna talk a little bit about that. And this is our time thresholds that were updated. What can be counted for the total time of the visit has not changed. When used for billing, time has to be documented and it is only the time of that clinician. So you can see where it went from ranges from an AMA perspective to total time, and you have to either meet or exceed that time. All right, ready to hit 23, Linda? Absolutely. I did notice, thank you Nicole for going over that, I did notice some questions that are in the box, and really kind of looking to the point of how do you find that external note, you know, we, I apologize, sorry, I have my husband letting my dog out, she would wait till I spoke to start barking, so I apologize, looking to see that whether we can count that external note when it comes from another specialist or specialty, but within our office, and Nicole, I'll ask you for comments as well, but you know, where they look at the definition of a new patient as being seen by the same specialty, and EP and heart failure intervention, that's not subspecialty, those are different specialties, but they are within the same practice, so I would not consider that as external, and I know a lot of the MACs don't. Anything you would add, Nicole? Correct, and that's what I've seen, Linda, if it's within your practice, and chances are particularly if it's an interpretation of a test or a procedure that they've done, and it's within your practice, most of the Medicare carriers have some data out there that they do not support that as an external source. Agree, and that's my understanding as well, so if Dr. A interpreted the echo, but Dr. B in your practice is pulling that up and looking at it, you wouldn't be able to get credit for that, for that review. All right, so now we're going to look at, you know, what happened with our hospital guidelines, and we know here that, you know, truly one of the bigger areas that we saw prior to this, and truly continue to see in a lot of areas, is that first statement on that daily visit, patient seen in follow-up. No, we got to have that chief complaint there, so make sure that you've got that complete thought process, you know, what is it that they actually are following them for? Other than that, they align very closely with the office E&Ms. So, I won't go back through these, but I do want to point out where it's a little different, so we still need two out of three, and if you look at that number complexity or problems, what's in red, that you can see that we've added that second piece there. Now, that's unique to the hospitals, where it says one acute uncomplicated or injury requiring hospital inpatient or observation level of care. So, even though it could still be low, you know, that was one of the things that I hear from a lot of my physicians and clinicians to say, well, you can't get a patient admitted if they're not at least in that moderate, and you know, that may be true. You may have fairly minimal use of that level one, but remember, you have to have two out of three. So, you know, how many have that stable acute illness and or an acute uncomplicated requiring hospital level of care? Well, that may be your one, so now we've got the exact same content in two and three. So, one thing I would point out is, so look in the center, you can see that you have to meet, see the little comment there, limited, must meet the requirements of at least one of two categories. So, you've got that any combination of two, then you've got the second category, assessment requiring an independent historian. Now, note that when you go down to moderate, now you need at least one out of three of those categories, and that independent historian, look at that, it moved up to category one. So, now it becomes an element of category one, and you need three of those, and or now you've got that independent interpret test, and or the discussion or management test. One of the things that I've encountered as we've trained clinicians, and they say, well, I always pull up their such and such image, I always pull up, it's like, well, okay, but you need to say it, you know, the difference that you personally pulled up that test and looked at it, you know, that's going to give you that credit there, that's what we're looking for. And the next slide, well, then what are we going to do to get to high? And here, you know, the same thing that we talked about, what's different here that the decision for a hospital level of care on the far right under risk, and also the addition of parental controlled substances. So, one of the things to, you know, communicate with your clinicians is, if they're going to be billing these in that level three, and I love the fact now that a three is a three is a three, whether it's initial, or follow up, or ops, you know, they're all at that same level, that was one of the wonderful things with the realignment, same as with the office that a new patient and an established patient, the levels are consistent now. But using the word severe, or using the words acute, if you're looking at that high definition of the problem, then putting that in there is just super, super helpful. And then we look at that second, you know, we know that most all hospital systems are going to document and update those daily labs, used to be, you know, the physicians would draw that little, we call them fish bones, and put the little numbers, you know, in each of the boxes, and there's more than three. So, okay, you know, did you meet that, but now we need one more, if we're going to count that. And that's where, you know, either pulling up that test, or having that discussion. I mean, did they talk to the infectious disease doctor? Did they talk to the hospitalist? Make a note of that, you know, that may be what really does that. So, you know, coming on that specialist note, or admission notes, or whatever, that's going to help to give you credit for that prior external, you know, the previous admission, then don't just say, you know, old records reviewed, that's going to give you credit for one, you know, reviewed the hospital admission from January, discharge notes, consult note, okay, you just got your three. So, you know, just knowing what to specifically say. And then I've seen a lot of folks talk about in that far right column, well, how do we know if that's drug therapy requiring intensive monitoring? We want you to say, you know, this is being a monitor for its toxicity. That's a great fallback. And we're using the word high risk, due to, you know, explain what is high risk about that procedure. So just, you know, very similar, but yet a couple of little points that are kind of unique. Next slide. So I wanted to share this for you. And I know this comes up maybe a little more with primary care doctors than it does cardiology. But this was the AMA's response on, okay, so if I'm the one that order the parental controlled, do I get credit for that the first day? Well, what about the next day? And the next day? And the next day? Do I get credit on multiple follow up visits? And you can see where they say, yes, as long as you continue to manage it, and you mention it, that yes, you could get credit for ongoing days, not just the initial day. So time, we talked about what time can be counted. And I think the big thing here is to make sure that the clinicians all understand that, you know, if they spend a half an hour pouring over the old records, they may want to think about that. You know, if they then spent more time with the patient, then more time maybe talking with family, you know, their clock is ticking for all of that, but it has to be documented. So noting the time that they spent, and it's also a good idea just to have a brief note, you know, what was the nature of how that time was spent? I see some places that say, well, no, you know, the doctor said 45 minutes, but they have to say 10 o'clock to 1045. That's nice, and it's probably best practice, but it's not actually required. Documenting the time is what's required, and it doesn't have to be clock time here. Now, we'll talk about critical care, and it's a real good idea to do it with critical care, but just on a daily visit, you know, and it doesn't have to be continuous. So they may have had that 30 minutes in the morning, and we're going to bill, you know, a level three already, and now they're back, and they're spending another hour, hour and a half with the patient. Well, if it doesn't qualify for critical care, and we'll talk about that, might it qualify for prolonged? So we need to think about that and how the time is documented. Next slide. So discharge, as we all know, this is only billed by the clinician of record, meaning that your doctor was the admitting, and they're going to be the discharging. You are the physician of record. If that patient was actually admitted and is going to be discharged by a hospitalist, then on the final day to see the patient, we would just use those subsequent visit cards, because this only has to be the physician of record. Now, we do have the option for over 30 minutes. So should the physician just say, spent greater than 30 minutes in discharge services? Probably not. You know, to say, yes, I spent 40 minutes due to, you know, extensive, you know, notes or communications with the, with the skilled care. It's good to give a nature as to why, and absolutely document the time as well. Observation codes. There was some confusion of this last year, and we, when we look at the observation codes themselves, it is just the initial hospital code that we're going to use unless you are the physician of record. I've been joined by a co-presenter. This is Maya, everyone. So the twist here is that if what we're doing is consulting, then we're not going to build the observation code. We would build that initial hospital visit, whether we're admitting or consulting. It's just very few payers. You can pretty much count them on one hand on who actually accepts the consulting code still. So you're going to build that initial inpatient visit when it's inpatient. And when it's OMS, you're going to use whatever of the outpatient codes applies to that patient, where they'd be new or where they'd be established. So here's what it kind of looks like. If you look at those 2023 work RVUs, it's really not a bad, you know, difference between the two. And then when you get to the subsequent, you can see it's actually there's an advantage to hospital follow-up. So here's the wording in case you, you know, had any doubts where Medicare is saying they're not changing the rules here. And this was last year. But if you're going to build the OMS code, then you need to be the clinician of record. Nicole, you want to talk us through this one? Yes, Linda, sorry about that. Well, I just had to put this up here because I know this is what we see on our rounding notes a lot when we're seeing those level three bills. And we see these copied over day to day. So this particular note, I didn't include the other two days, but basically everything from the pre-tax assessment and plan notes to 10-5, the data at the bottom, was basically copied for every day. And 10-5 was really my only updated documentation that says the patient feels better, the heart rate's better controlled, blood pressure's better controlled, they're recommending a cardioversion, they may be discharged, and they recommend Eliquis for rate control. And when you really look at this note, there's nothing I can get to that would meet a level three rounding visit here. Particularly with looking at copy-paste, yes, the patient is on high-risk medications, you could say from an anticoagulant basis, but they don't talk about how they're monitoring that or what that risk is. And then, of course, their conditions are stable. So I think we see this a lot. So just a reminder with those level threes, particularly as the patient's being discharged home, Medicare definitely states that they would expect to see progression or improvement in that patient's condition as they move toward discharge. Thank you, Nicole. All right, split shared. Man, this one's been a bit of a roller coaster, hadn't it? So when we're talking split shared, excuse me, in a hospital setting, we're talking about a service when both an MPP or APP and a physician see the patient. We know we need to attach the FS modifier that's going to alert Medicare to the fact that, yes, this involved both an APP and a physician. And I know many of us kind of came up with templates in the hospital that's going to help our clinicians as they document. So having a template is certainly helpful, but let's talk about what are those critical elements within that. Now, when we look at the critical care code, we know that where it used to say a service could not be rendered or eligible to be performed as split or shared. We know that we can now do that. And even though CMS gave us a pass on only using time for some of the other visits for critical care, you know, their thought was, well, that's already a time-based code. You shouldn't need time to prepare for that. So for critical care, you do need to make sure you document who spent the most time. And they left it up to us to decide how to best do that. But bottom line, you probably need to document time spent by the APP and additional time spent by the clinician, and you wouldn't double count any time that they spent together. So this was where CMS was standing. So, you know, we're not talking incident two. Incident two is what we're going to follow, and we're in an office setting. This split shared is what we're talking about in the hospital setting. So, you know, their thought here and what it boils down to is how do we better perform substantive? What's the definition there? And that's what they've been looking at. How should they define? They were proposing who spent the most time. They got enough feedback from the medical community saying, no, no, no, no, we disagree. You know, we, it is, you know, they may have spent more time, but we did the critical piece in the decisions that were made and how we treated it and the risk that we take. And, and so they've delayed it. They said in 22, they were finalizing it for 23. Then in 23, they said they're going to delay it till 24. Well, now in 24, they're going to delay it to 25. But with one change, the AMA has added a definition into the CPT book. So CMS says, well, we're going to defer and, and use the AMA's definition. But what does that really mean to our documentation? I think we're not yet sure. If we look at the CPT language, you know, we've got that split shared definition of the substantive portion is what it's revised. So coming straight out of the CPT book, you can see what I've, what I have in red here, and you can see what it states. For the purpose of reporting E&M services within the context of team-based care, performance of a substantive part of the medical decision-making requires that the physician or other QHP made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan, along with its inherent risk of complications, morbidity, or mortality. Well, you know, that would almost infer that as long as the physician is accepting the risk that, okay, they met substantive. But I don't think we can jump to that conclusion. I've seen some say, and if you want to go to the next slide, that, you know, what that does is help meet the actual documentation guidelines for split and shared, but then does it also meet the definitions for level of service? And are we talking one set of guidelines or two here? That's kind of where the discussion is. I can tell you in our organization, we were trying to make it as simple as possible. We didn't want the physician to have to rewrite an entire note. And I think everything that we've said, you know, the intent is not to do that, but then what do we do? So we came up with a template that I'm showing you here, and we wanted it to be able to be used, whether they were doing this with the APPs and or with residents or fellows. So they can just click the box that applies that I saw them in the presence of, independent of, or I just had a discussion. And once they click that, it drops down these other options where they can put in their exam findings. And that was great. I mean, that could meet substantive for 21 and 22, but in 23, when the level of decision making is not based on history and exam, well, now that MDM and what gets added there, that really gets important. And I know a lot of people are asking, well, exactly how much has to be said? And, you know, we can't really answer that with any certainty. We know what can work, and I think we've got to kind of look at what doesn't work. I know Nicole and I were talking earlier today, there's various newsletters, you know, the compliance alerts and different speakers and different venues. And this is a very active discussion on, okay, well, can we meet that CMS definition, or I'm sorry, CPT definition of assuming the risk, does that also equal CMS and level of service? That's kind of the unknown. So really, I know a lot of organizations in 23 went ahead and took the position that we need a statement to support level of decision making within their addendum, you know, to just say, agree with APP. Well, you know, I've had clinicians say, well, if I agree, then I've read the whole note. And if I'm cosigning, isn't that also my note? You know, and that's a valid argument, but that doesn't necessarily mean it's going to be accepted by an auditor. And I think, you know, back to that very first slide where we started, you know, that medical record serves multiple purposes. And part of the documentation still, you know, clearly supporting that physician's personal assessment and plan to say that this was a substantive participation. Agree, that might work with a teaching physician, but is it going to work here? I think, you know, the safest recommendation we can say is look at the two of three elements. It doesn't mean you have to rewrite the whole note. But if you had something that says, okay, a severe AMI with CHF excerbation, going to continue that parental control fluid, monitoring for toxicity every day. Well, I just met column one and column three. So, you know, how much needs to be there? We may get more from CMS. But for now, I think we need to think of it as it's going to be best that until we get other clarification, that whatever the physician documents is enough to support the level of service that's going to be built. I know Nicole and Jolene and others, you've listened to some of the carriers do some of their education. Have you gotten any more insight into this at this point? No, Nicole, I think all we've gotten so far is basically just what you're saying and what is that going to look like? And I think the part that we keep hearing is the part around that it's going to determine the level of service. So again, how do you meet that level of service and what's documented? Does it require documenting the complete assessment and plan all over again? Not necessarily. And I think the other thing was, is what if both APP and physician document the medical decision making exactly? Well, I think you got to figure that's just not going to work. If it looks the exact same and says the exact same thing and the physician copied it. I don't know. I just, what are your thoughts on that? I just don't know how that's going to play out. Yeah, that makes me uneasy. And the recommendation that, you know, the doctor re-document, I just feel like that opens us up for potential issues. You know, what if the notes are a little bit different? Now, whose note did they follow? You know, I think it goes right back to, you know, where we started. It's that care communication. I don't want to increase the risk of patient safety, you know, or there's a question on whose order trumps whose order. You know, I just don't think documenting both is the right answer because now you've got people reading both and trying to determine which one. And I really hope we get some updates soon. Here's the examples that we use, you know, in the office. Now, I know we're talking about in the hospital setting, but remember, if you are an office-based, your clinic is a hospital outpatient or PBB, you're going to need that similar documentation. So, you know, whether or not you were with the APP or not, do you do, you know, do you have the APP just do the beginning and the physician come in and do the end? You know, your organization needs a plan. Make sure you know that if you're in a hospital outpatient department for your clinic, don't forget that split shared applies to you there as well. And Nicole, you want to talk about this example? Yeah, so this is what you were talking about, Linda, around, you know, the physician came back in and saw this. Yeah, they have with their agree statement here. Of course, this is a 23 note, but then you can see they seen it, examined the patient, and then the physician clearly document. The top part is documented by the APP, the bottom by the physician, and then they both sign it. But the physician's documenting the conditions, documenting how the patient's doing, and then also their medication management. And I think, like you said, he's not getting necessarily into all of the data that was reviewed in the upper part of the note that I don't have here. But again, what are those sentences that could support the level of service and that the provider was the physician who performed the medical decision making? One thing I wanted to mention, Linda, I see a question about physical exam and is it required for the physician? Just as you know, the physical exam can be done and it's just not a determining factor in the split shared. Anything to add on that? It can be done by either provider. It doesn't have to be done by both. One provider has to see the patient, but it doesn't determine that level of service in any way who the billing provider is. Agree, agree. And we both agree, Linda and I, and we'll say it on here, that having an attestation only that agrees with everything the APP documented does not support the definition of who the billing provider is for split shared. You have to have that medical decision making two out of three of the components. Thank you, Nicole. All right, so critical care. This isn't new, but we've certainly found that a lot of people kind of miss some of these nuances. I wouldn't say that Medicare changed their rules, but what they did do was put out some clarifications. And I can tell you when we went back in my organization to clarify with the coders and say, okay, talk to us about what you do when you see X or what you do when you see Y. We did not have consistency between the coders. So it's not a bad idea to just go back and kind of reload on some of these pieces that can be confusing. So of course, the definition of critical care, that didn't change. You've got to have that critically ill injured patient. You got that acute impairment, one or more vital organ systems, probably not just the fact they're in the ICU. We've got that high complexity medical decision making right then, right there, requires that full attention of the provider. They can't be busy doing anything else. And that time, if they do procedures, it's super important to make a comment that your critical time that you're counting does not also include any procedure that was performed and billed for. And here again, it's a time-based service. Time must be documented. Now, is it probably considered a best practice here to say I was with the patient with my undivided attention from 10 a.m. until 11.15? Is that best? Probably, because you might have the pulmonologist and infectious disease and other people who also build critical care on the same day and the records are gonna be requested. And seeing that you're not both counting the same time is certainly a good thing to have noted. Now, Medicare did clarify there would be exceptions that they might have more than one specialty treating the patient in a situation at the exact same time and it could be covered, but man, that medical necessity is gonna be critical. Examples of that might be the trauma physician who was addressing maybe an injury to the legs or head while the cardiologist was working on the cardiovascular system, trying to stabilize that. It's not that it could never happen, but it's gonna be infrequent and then you are gonna wanna have it clearly documented. So of the things that I find clinicians did not realize were separately billable, if you notice that list of what's not bundled versus what is bundled, CPR. So if they call our physician to run a code and it takes them 30 minutes to revive that patient and then they are still on that unit, further stabilizing them for another hour, hour and a half, you can bill both. But that would be an example of saying time spent in critical care X to X not counted in critical care time from Y to Y. So just making that clear and making sure they do understand that. So what were kind of those highlights from my perspective of clarifications? Nicole and I talked about these and we presented them last year at the cardiovascular or the CV summit. And I can tell you in that room, there were so many physicians. And maybe the coders heard it, but the clinicians weren't aware or didn't actually digest it. So I think these are the areas to just kind of spot check, maybe circle back with your coders, compliance folks, your clinicians, and ensure that they truly are aware of these things that let's say that we admitted the patient at 8 a.m. and at two o'clock they crashed. So as long as we are documenting that we, yes, when we admitted them and we were finished, we walked away, we were providing care to other patients and then they crashed and we had to get back there at bedside. And we had to get back there at bedside and stabilize that patient from two to three o'clock. Those are both billable. You can bill that E&M and the critical care. And that was one of the biggest things that when we talked to coders and we said, okay, so what happens if the physician turned in both? They said, well, we don't bill both. Well, you're not gonna be able to make that assumption. You're gonna wanna look at the time and was that E&M first and then critical care later at a completely different time with both the time and the nature of the service documented very clearly. The fact that critical care can now be rendered as split or shared. So looking at the example here, let's say that the APP is hospital based. So they were already in the unit and they spent 15 minutes before the physician arrived. And then you spent 20 minutes together. Okay, well, you wouldn't count 20 minutes for each the APP and the physician, but you would count it for one of them. And then you add the physician time. Now you don't count the time they both spent twice, but the physician who's the billable, whether it's the physician or the APP, it's gonna be determined by who spent the most time. And you would add your times together as long as they were independent. And the one who spent the most time is the one who would bill. And having the documentation that says, this is the time the APP spent, and this is the time the MD spent, having that documented in actual time is probably a best practice as well. But just the main thing is don't count combined time together, but separate time you would put together. Family discussions. This was another one. We had a physician that was sitting up near the front and she just slumped in her chair. It was like she was gonna fall out of her chair when she heard this. She said, I was told that I can never bill for family discussions. Well, that's an oversimplification. There are times when you can, and the time that you can is here. When that discussion with family has a direct bearing on that patient's care time, and the patient's not doing well, maybe they've not documented code status, this isn't just a regular, mom or dad's doing much better today, we're a little concerned about this, that's not billable. But when you document that I had to have a discussion with family because the patient was unable, they were sedated on a ventilator, and I thought I might need to make a decision that was gonna take their impact. Noting that, and then the time spent in that discussion can count towards that. So understanding that piece too, and then looking at that same specialty critical care, there is subsequent critical care. This one was big for the hospitalists that they thought that, well, I can't bill for my critical care because somebody billed critical care earlier in the day. Oh, but you can. This is just, you would be subsequent critical care later that day. So I would suggest that you kind of go through each of these, check with your compliance department, your coders, make sure that they agree with the interpretations and the message, and then make sure your clinician's understood because Nicole can attest, we had some, as I call, scooby-doo ears where they just kind of cock your head and look at you and say, what? And definitely some confusions here. Next slide. So here's just a little more that we talked about, family discussions. I won't go through the slide, I'll leave this here, but these are the pieces that it's critical to document in order to go ahead and get that documentation for the family discussion that can be counted towards time. Teaching guidelines of critical care. Here again, you're not gonna count time by the residents. If the teaching physician's not there, the teaching physician can refer, but they're gonna need to make sure that they fully meet the definition personally and then document that time. This is the template that we have. It kind of prompts the clinician to fill out the blanks so that we now have all those critical elements and then they free text anything extra. So if you don't have a critical care template in the inpatient setting, this might be a good example for you. So just this piece, like I said, just truly, we know now it can be done as split shared and they did leave it up to us to say, how are we both gonna document? I think it's pretty clear that both clinicians need to document their time. From an auditing perspective, you know, it really kind of rolls up into that blue box, but there's nothing I love more than to see the sentence start out that says, I was called urgently to the bedside for, you know, that, you know, if you can't say that, it was like, well, no, I'm just making rounds in the ICU. It was like, well, then maybe that's not critical care. So these are all the different pieces that I really like and I like to share those with my clinicians. All right, so let's talk about prolonged services. Prolonged services, we have had significant use for this in that inpatient setting, as well as in some of the office visits by some of our other specialties. And really what we've got to think about is time-based services. So, you know, if you're gonna build prolonged, you need to already be at the highest level of whatever that E&M service is. That describes whether you're admitting or doing hospital follow-up, or you're in the office as a new patient or established patient, and then exceeding that time by that full 15 minutes. So, you know, that greater than halfway mark that some time-based codes allow does not apply here. You do have to exceed it by 15 minutes and your time here can be counted both face-to-face as well as non-face-to-face, non-face-to-face, as long as it's on that same day. That doesn't work with the psychotherapy codes, but hey, we're not billing those, so that's all right with us. So the documentation guidelines, this is the piece that we're gonna be in a bit of a holding pattern to see how CMS is gonna handle this. Because at the time that these came out, Medicare did not agree with CPT. So as a result, they come up, they came out with their own G codes. And so, you know, it is prolonged care, it's time-based. You have to have that actual time, you know, not a range, doesn't have to be continuous, but it has to be on the same day as that other visit. A brief note that says how you spent the time, you know, maybe there as an example, review of extensive medical records from multiple clinicians. If you did bill something, that is a time-based code or another service saying does not include the time spent, rendering whatever service you may have billed in addition to it is also gonna be an important statement. And that's where the documentation guidelines agree. Yes, you can go ahead and go to the next slide. So you've got, you see the list there on the time they can spend. Now, notice that CPT says beyond the total time of the primary procedure. And Medicare came out with their own code and said beyond the maximum required time. That's the key difference. Now, as Nicole talked about earlier, at this point last year, we had time ranges in the office-based E&Ms. We no longer have a range. So what is that truly gonna mean? It's hard to say when we have to go with what Medicare has published, which is use according to the 23 guidelines. So let's look at this. What are those differences then? So CMS didn't agree with those guidelines as stated by the CPT. So they came up with their own rules. And for prolonged services, I thought this was an interesting twist that commercial payers as well as Medicaid will use the CPT code. And only the G-code for Medicare traditional and replacement plans. And that may be different in your areas. I can tell you, but here in Indiana, Medicaid does not acknowledge the G-code. They want the CPT code. So we're only gonna look at the time for the date for the encounter. And for those of you who service multi-specialties, just know that there are separate codes for nursing home and home visits that we won't go into today. But those do consider additional days. And I'm just gonna leave it at that to not confuse the matter. So note that on the office, we had these time ranges. This is in 2023, make a note on there because we know that come 24, that range went away. Now the differences between what Medicare expects to see and what the AMA says is okay, it's fine on the hospital side because you'll notice the hospital side, it already had a flat time. It didn't have ranges. So there wasn't any confusion there. The confusion came on the office-based side. Next slide. So CPT and CMS disagreed on their use. CPT says prolonged can be added after we met the minimum time. And I'll show you a slide here next that explains that while Medicare said, no, no, no, it needs to be the maximum time plus 15 minutes. Go ahead and go to the next slide there and that illustrates this. So the Medicare came up with different codes. These are the ones that are in effect now and they did not state in the final rule that these were going away. So they haven't stated they're deleting them. So we know we need to use them now in 23. We'll have to see what they say about 24. So here's the rub. So look at that time range. Let's just focus on an established patient, 40 to 54 minutes. Now per CPT in 23, you could bill it as soon as you exceeded it by 15 minutes. So, okay, but Medicare said, oh no, no, no. You need to be at the maximum, then add 15 minutes. And I'm kind of with CPT there. I mean, because if you look at the minimum range of 40 minutes for CPT, add 15, you're at 55 minutes. Well, that's only one minute over the time range. And that was the part I had a really hard time wrapping my head around. It's like, how is that okay? I kind of leaned towards Medicare and their interp here that that just doesn't seem right. I've got you, this is the grid. And this is what Medicare has said and what's in writing. And when they updated their E&M guidelines earlier this year, they did clarify that, no, they want that maximum range time plus an additional 15 minutes. Then you would meet it for another 15 minutes before you could add another unit. So I've kind of given you the, when could you support a second unit down below? So what does that mean? If we look at 24, now we're absent the time range. So you can see the AMA, the actual time ranges there and AMA would say, use it at 15 minutes. That would infer that that G-code would also be at 75 minutes, 60 minutes plus a full 15. Well, that's just inferring, that's just following CPT. And I've got that highlighted because we need to see the CMS update and see if they acknowledge that. Because what we have now is what they published in 23, but knowing that that was because of the time range that's now gone. I don't know, Nicole, anything more you would say there other than we just really need to see in writing from Medicare? No, I agree. And I think you and I talked about that. Lynn, there is a question about, I'm interested from your perspective, since it is related to the prolonged services. It talks about that some of the commercial payers aren't recognizing the 99417 as a billable code. Of course, Medicaid, we know they have their own. Have you heard of anyone appealing that or using the G-code with a commercial payer? Has that kind of just been really payer dependent? We have appealed. And I can tell you, we're not seeing too many issues with it, really. I really thought this would be one where it would be kind of on that list that the payers just automatically request notes. I mean, we know that happens almost every time we build critical care. And I really thought this would kind of go on that list. And we're not seeing that. However, we did find that Anthem Blue Cross Blue Shield, they have a policy on it and they have a medical necessity policy and they deny that code if it's billed with a diagnosis that does not appear on their medical necessity policy. So we have seen denials from Anthem Blue Cross Blue Shield for the absence of medical necessity and not being for a condition that they have listed in their policy. We have appealed to their medical director wanting to have certain conditions added. And that's kind of a wait and see. Gotcha. Have you tried the G-codes at all with commercials, Linda? We have not, we've not. Well, by accident, I guess. By accident, we did. And then we wrote a rule in our whole billing system to hold a G-code going to a non-Medicare payer. But we did get denials when we billed G-codes to commercials and because of that, we wrote a hold that to catch those up front. Someone did comment that UnitedHealthcare in their area does require the G-code for prologue. Okay. That could vary. Well, it's like, I feel like whether you fill in the blank with, unless it's United, unless it's Anthem, Blue Cross, we could take almost everything we say and- And say that. And say that. It's always interesting to try to understand and learn those little payer to payer nuances. And I think that's something that, certainly an advantage of an organization like MedAxium where you're functioning in multiple states. And so you have the ability to see what works in one state may not work in another, and what works here or one payer doesn't work in another. And that's why you'll see so many references too, but you have to know what the payers in your area want because there's just not a whole lot that you can say always and never about. Yeah. And I think sharing that on the listserv always helps someone, could help someone in your region. So feel free to share anything payer specific if that's how you learn from each other, for sure. Yeah. Now these codes, Medicare, these prolonged D and M, Medicare made these ineffective. They consider them bundled, they won't acknowledge them. Now we had been using these and to pretty significant success in 21 and 22, these are still billable to commercial payers. So if you're having problems with either of the other two, you might try this one. This one opens the door for before or after direct patient care. So the use case we had for this was a lot of our patients for like chronic total occlusion and or some of the transplant or heart failure patients. The clinicians might spend an hour, hour and a half reviewing records and going through everything on a day that was not the same day as an E&M. Well, when Medicare said, these codes are going away, we're not gonna pay for them anymore. Well, that was the equivalent of saying, we're not gonna pay for things that aren't done on the same day of the visit. The codes aren't identical. This is intended to capture some of that other time outside of the same day as an E&M. So I felt like I would be remiss if I didn't at least acknowledge that they were still here. And these would be some that would be billed if maybe the physician did it the day before or the week before, but you wouldn't bill the code until you know that the patient actually kept that appointment because you do have to ultimately have that appointment with the patient. So I just wanted to mention this, if they are spending extensive time on a day other than the E&M. So here's how it all works out. Like I mentioned, I'm not gonna go into the nursing home and home visits. If you happen to have someone that's doing that, just know that, well, now for whatever reason, you do get time both before, one day before and three days after there, but it's just a recap of the time here. And like I said, this is the AMA showing the range here. It is an unknown as to what will happen now. It would still require the 89 or will it be 75? We'll have to wait for the update. And let's just go beyond that. And that's just something you can look to. Oops, well, hey, there's that slide I was gonna update. Yes, Blue Cross has a policy and we talked about that. So we can go on to the next slide. All right, I bet you guys are all wanting to hear this. I know we've got clinicians who are pretty darn excited. The complexity code, we saved this for last. All right, so we can only share as much as we know. So what we know is that it came out with this MedLearn Matters, and this is where it confirms that the complexity code will not be an option for use if the E&M that we're billing has the modifier 25 on it. So now let's think about what that means to us. An E&M on the same day as a device check, on the same day as an EKG maybe, on the same day as a flu shot. Think about what are those things that we do on the same day as smoking or tobacco cessation. When are we billing something more than an E&M that's a procedure that then requires the 25 modifier to be attached? I know I've had docs, especially primary care doctors saying, I need a list of all the times it requires. And it's like, you know what? It's gonna be a lot easier for me to tell you the times it doesn't. We know it isn't required, at least by our payers and by CCI edits on venipuncture. Pretty much anything else we're gonna bill, yeah, we're gonna need it. So we know that you can't bill it if you're also doing something else on that visit and your E&M has a 25 modifier on it. This has been published. And other than that, what we see from CMS comes right out of the final rule. And I'm gonna share with you some of these examples. So Nicole and I went through this and Jolene and Jamie, we kind of said, all right, have we got the key pieces here? So it is proposed to take effect January 1. As we talked about, you can't bill it if the E&M that you're billing it with also has a 25 on it. It's only gonna work in the office or outpatient clinics. So this is not gonna be hospital-based. And one thing to just acknowledge is here in red that the implementation of this code, it is thought to be very closely linked to the conversion factor reduction. So we know that Congress has already broke. And if they're gonna give us a pass on the conversion factor reduction, then it is very likely that they'll say, well, we'll not take such a big cut in the conversion factor. But if we're gonna do that, well, then you can't also implement this code. And that's what happened in 21. This code for complexity was also proposed in 21. And then remember, that's when the E&M guidelines changed. And they were acknowledging that even with the new guidelines, it really doesn't take into account some of this other stuff. They just felt like it doesn't take into account all the things we do in between phone calls and the other pieces and just everything that just goes along with some of this other complexity. So it's thought that they may do that again. This code alone adds payment and Medicare has to keep the budget balanced. So if they are gonna pay this, that's adding a big chunk of money. I've heard estimates as high as 30% of the conversion factor reduction is due to this code. So as a result, not all doctors are happy about this. There's a bunch of organizations as well as specialties that are asking Congress not to implement this code. Because what that means is, they're gonna take the conversion factor cut on all their things like some of their surgeries and yet maybe not meet the definition of having that longitudinal relationship needed to build this. So they're kind of coming at it as, well, wait a minute, that's not fair. We'd have to take the cut and only this other group of clinicians is gonna get this code. So this is a bit of a waiting game. And I know we've got some awfully excited clinicians, but I can tell you in our organization, we've made the decision to hold off and not suggest filling this come January 1. But to just hold on this for, whenever they do have that vote, we hope it's mid-January, but we'll go over what we know about it, but just know that, yeah, we may be getting excited and it just end up in a big wah, wah. So definition, complexity inherent to an E&M associated with medical care services that serve as the continuing focal point for all needed healthcare services. That's part one. Part two, and or with medical care services that are part of ongoing care related to a patient's single serious condition or a complex condition. All right, well, that's what takes it outside of just the primary care area. Maybe primary care is the focal point for all needed health services, but we in cardiology, well, we certainly meet that second piece of we have that ongoing care related to a patient's single serious condition or complex condition. So the really at issue here is this last bullet that Medicare stresses that what this is trying to do is really to reflect the intensity and the resources involved with enabling that practitioner to build a longitudinal relationship with the patient. That piece is key. If it's a visit that we think is gonna be a one and done, we absolutely don't qualify because we don't have that longitudinal relationship. So it's like, okay, well, how many visits equals longitudinal? How many times equals longitudinal? Well, we don't know yet, but we know that it's expected to have consistency and continuity with delivering the care over those patients. I mean, things like, let's just talk about our heart failure patients. We know we're gonna see them, some of them once every couple of months, some of them monthly, some we've been following for years. Is that longitudinal? Absolutely, and we can probably give all kinds of other examples. So we go to the next slide. You know, what do we think? Well, Medicare said by certain specialties, now they were inferring those who are primarily E&M based specialties, that this might be billed as high as 90% of the time. But then they also said that specialties that are high in surgical services would be the least likely to bill. So they did make it a point to say, okay, if this is a discrete routine or time limited nature of that relationship, and the examples they gave there was seeing a dermatologist for mole removal. You know, you're not expected to see them beyond that for fracture care, you know, things such as that. And it's like, okay, well, if they're talking about complex, does that mean it would only be billed to higher level E&M codes? No, it does not. It is not limited to only the higher level codes, nor do they name, you have to have certain conditions, and it didn't even say that you have to be addressing that serious or complex condition on the day of the visit when you bill it. So it's like, okay, well, how do we know when to bill it? Which is what everyone wants to know. And then what does the documentation gonna require? We know we've got a work RV value of 0.33, and this adds on to an E&M. So we got some clinicians that are pretty darn, you know, excited about this. So what do we think about our cardiology patients? You know, do we think they're gonna bill it? I think so. You know, many, if not most of our patients, we have that longitudinal relationship with those patients, and we render medical care that's an ongoing care related to a single serious or serious condition. So I think we do meet that two-part definition in lots of cases. What documentation is gonna be required? All we know is what's in the final rule. We think that CMS will release additional guidance. They comment in the rule that they would if it becomes apparent of the need to do so. I'm thinking it should be apparent already, but maybe not, we'll have to wait and see. But we know that key to this is that relationship and that we're following conditions and we have a longitudinal relationship. So, you know, should we have a sentence that, you know, says, you know, following this patient on an ongoing longitudinal basis and evaluation and management of their, should we have a sentence like that? That's probably a good idea. I mean, if we don't hear anything more before January and implementation, having something that supports part of that two-part definition, that's really the best guidance we can give you. Now, I will give you word for word right out of the final rule, the two examples that Medicare does give for when we would bill it. And one of them I think very closely correlates to cardiology. So in this example, we see an HIV patient encounter. So the patient with HIV admits to their infectious disease physician that they've missed multiple doses of their medication in the last month. And now the infectious disease has to weigh their response during the visit. And look at this here, they're taking into consideration the intonation in their voice, their choice of words, so that they're communicating clearly that it's important to not miss those doses, but, you know, also to create that sense of safety in sharing that information so that the, you know, if it goes poorly, it could erode that trust over time. The patient may not tell them that they haven't been adhering to their medicine, leading the physician to maybe switch medicines to those that have greater side effects when really there was no issue with the first med. Now, how many times could we maybe crosswalk this to our hypertension patients, our heart failure patients, some of, you know, our other patients where, you know, switch out the HIV med for any of those cardiovascular meds and infectious disease with cardiology? I think, you know, this whole piece, you know, we have to do this. So even though the infectious disease doctor is not the focal point for all services, such as in the previous example, which I actually am gonna make your next example, it is still that serious condition. So this is the one that truly, I'm using the word surprising here, that is my wording and I think probably all of ours. I would, if I were to sit through and think, you know, what advice am I gonna give people on how and when to bill it? I would have said, you know, don't bill it on a visit that's just a simple thing, like the example they gave here, sinus congestion. So that's why I'm saying this is a surprising example. So look at this. Okay, so they're the continuing focal point for all the healthcare services. They're gonna see that practitioner and it's for sinus congestion. So it's not the inherent complexity code that this code captures is not the clinical condition itself but rather the cognitive load of the continued responsibility of being the focal point. There is previously unrecognized but important cognitive effort utilizing that longitudinal relationship itself and the diagnosis and treatment weighing different factors. And look at what it says there. So the primary care could recommend conservative or prescriptions or antibiotics. If they recommend conservative, no new prescriptions, some patients may think that the doctor's not taking their concerns seriously. It could erode the trust. So in turn that eroded trust may make it less likely the patient would follow in the future. So here again, we get that same parallel. You know, they have to decide what's the course of action, the choice of words that would lead to the best outcome while simultaneously building up an effective, trusting longitudinal relationship, weighing these factors. And it is complexity in that relationship. So that one really kind of took me aback. So, you know, what can we tell you? You know, when would you bill, when would you not bill? Well, you know, what we're telling is coming straight out of the final rule. And, you know, it's kind of uncomfortable to elaborate anything outside of that because then it is just, you know, our foresight, our insight. You know, I've had somebody say, well, would you be comfortable with a new patient? Well, you know, that's probably a good example. It does not mention anywhere in the final rule that it's not eligible for new patients, but it does stress longitudinal relationship. So, you know, that kind of infers, you don't know yet if it's gonna be longitudinal. And I just haven't seen anything more. Any of you have anything more to add? Nicole, Jolene, Jamie, have you seen anything more on this? Yeah, no, Linda, I have not seen anything more. I think it's also important to know that if the patient, just because if it's a complexity code, doesn't mean it's high complexity necessarily. So we had a question like same day clinic, the patient's coming in, the physician seeing as established patients having problems requiring immediate attention, that doesn't automatically meet the complexity definition. Would you agree with that? Yeah, and, you know, if we take this definition of sinus congestion, you know, Medicare is not limiting it to only complex, but if that's the same day walk in for a quick pre-op need or something, I'd say you don't meet the relationship piece. So yeah, it is definitely that two part definition with the biggest emphasis going on that longitudinal relationship. And I'm just not sure that that, you know, type of work in quickly, you know, if that's an established patient that you've been seeing for 10 years and was in a couple months ago, and now they're in acute excerbation and you get them in same day, okay, you know you have that longitudinal relationship. But if you're just working them in from a primary care because you think it's a significant issue, I don't know. I just don't think that's gonna meet the longitudinal piece yet. Yeah, I agree, I agree. And I know we have some folks commenting that the AMA at their round table said they were gonna be sure an MLN was gonna come out around visit complexity and the assessment of social determinations. I'm sure it will as well. I think, you know, we'll definitely see those. It's a matter of when we're gonna see them. Yeah, I agree, I agree. And I saw a question where someone asked, well, if we can't build that prolonged on a day other than E&M, what can we build? Nothing, you know, and there isn't a crosswalk to it. Now, what you might consider, and I know we are gonna do some education coming up in the new year. You know, Medicare did come out with some other opportunities for the first of the year. And if you've not listened to the 2024 webcast that Nicole and I did with the ACC, you might wanna go back and listen to that. There are some services and, you know, let's think about what are the things that we can bill for time spent related to the care of that patient that did not also involve a visit on that day? Well, it ends up in the care management services. You know, chronic care management, complex chronic care management, principal care management. Those are the types of codes that might account for that. So I guess I jumped the gun a bit when I said nothing, but those codes all come with additional criteria more than just time spent on a day other than the E&M. So watch for future sessions and education on that. I think there's a lot of interest in understanding some of those opportunities and we will go through that. All right, everyone. Oh, you got, you see another one, Linda? I think we're- Yeah, I see, you know, is anyone gonna discuss how a 25 modifier really doesn't make sense? Well, you know, we can discuss it, but we can't make Medicare rule, you know, and Medicare does acknowledge that. There is, you know, they always give the, these are the comments we received and here's our response and these are the comments and these are our response. That's why the final rule this year is 2,709 pages. And I can tell you the E&M section, the complexity code, oh, what is it, Nicole? Probably 30, 40 pages. And they do talk about that, and the concerns and comments raised that, well, but typically a primary care might do a preventative and an annual wellness visit along with a sick visit and need the 25. And, you know, if you can't do it, people may not do them on the same day anymore. Well, you know, they said, CMS said, well, we'll monitor for that. We'll see if people stop doing certain things together just to avoid the use of the 25 modifier. So, yeah, I mean, I think it's, you know, and there's a lot of other questions here saying, you know, if the G221 is carrier driven, if a carrier wants a 25 modifier, is it acceptable to bill the E&M with no charge for the EKG just to get that additional revenue? I don't think so. I mean, we have to meet. Yeah, you know, compliance guidelines say we bill with what most accurately describes the service rendered on that day. And I think, you know, we can't tell you to do anything other than follow the billing guidelines for what accurately represents. Medicare did say they would take it into consideration. So, you know, if this goes through, and remember, it is still an if, if it goes through and it comes back around, you know, to maybe next year, maybe some of the comments that they'll get from the public, they'll maybe reconsider and do it separate. But as it stands right now, yeah, I. Yep, this is what we got right now. It is, it is. And I see a comment there. Are you suggesting we not bill until Congress votes again? That is absolutely 100% your practices, individual decisions. I think what we have to understand is if we bill it and it goes through and is paid, and we get the pass on the conversion factor, and Congress says you can't implement, well, what's gonna happen to that? They're gonna come back and recoup it. Yeah, so, you know, it is absolutely up to you and your organization as to what stance you wanna take and how you're gonna deal with it. Cause there's a lot of ifs and maybes in there. Absolutely. Well, thanks everyone for being so engaged. This was a great one. We will plan for more of these sessions as we go into next year. We know there's always complexity and questions around many of these. Stay tuned to the listserv. I hope all of you have a great holiday. Linda, RCS team, we appreciate all of you and I hope you have a great day. Thank you, everyone. Thanks.

2021 guidelines

2023 guidelines

medical billing

coding

documentation

split shared services

critical care

CMS add-on visit complexity

accurate documentation

prolonged services codes

Medicare

commercial payers

complexity code