All right, well we'll go ahead and get started. Good afternoon everyone and thank you for joining us today for our third boot camp session this week. My name is Jamie Quimby and I am a Revenue Cycle Senior Coding Consultant. I am joined today with Nicole Knight who is our Executive Vice President of Revenue Cycle Solutions and Care Transformation. Today we're going to be taking a deep dive into the 2023 evaluation and management changes. So let's start with covering some housekeeping items. To access the slides for today's presentation you'll need to click on the chat box to access the link there. Please do not use the chat box for anything else, especially questions. For questions you can submit those through that Q&A box. As always we ask you to keep your questions on topic and know that we will be answering as many questions as we can. We will also compile those questions though and add them to a Q&A document which will be uploaded onto our Medaxium Academy website. With the holidays approaching this may not be added until after the new year. We do get a lot of questions back on how to claim your CEU certificates. I know we've covered this this week heavily but we'll continue. An important item to note you must go into our Medaxium, into your Medaxium Academy account and click on the coding boot camp webinar you're attending. You will then click on the claim CEU box. Once you do that your certificate will be pop up and be available to view and download. You'll be able to download it onto your desktop or you can print it however you like to do it. A copy of it is also saved in your account so if you ever need to go back and re-download or reprint it you do have that option to do that. So again with our new education platform we have a new process with our CEU certificates. So the coding CEUs for AAPC those are the ones that will be available to view and download in the transcript section of your Medaxium account. Again we do ask for one to two business days to allow time for our team to get that certificate uploaded to your own personal account. Please note you do have to launch the webinar in order to obtain your CEU credit. CEU certificates are also available right now for BMSC holders. If you need that certificate you can email Jolene Breuder directly to request it. Some announcements that will be effective in in 2023 for AAPC CEUs we are going to offer between four to six webinars next year that will be offered on demand. So that'll mean you can listen to it after it's been presented live. We are required to have you take a quiz though in order to obtain that CEU. If you listen to the webinar live as it's being presented you will you do not have to take the quiz you'll be able to get the CEU certificate without having to take that. Also exciting news we will be starting to offer AHIMA approved CEUs next year. If you are a current AHIMA member they do accept AAPC CEUs. They're kind of selective though and I know this from personal experience because I have an AHIMA credential. So most of the times there's no issues with them accepting but occasionally you'll see one that kind of pops in a box below where it's they're not accepting it. So moving forward to 2023 we will have a separate AHIMA CEU certificate for anybody that would need that. As far as the BMSC CEUs we will no longer be offering those in 2023. The amount of people that requested is very minimal so moving forward we're just going to eliminate that one but add the AHIMA one. Okay so let's start with some informational overviews of the upcoming changes to our evaluation and management services. So this is an area that hasn't changed medical necessity and we we hear this term with every single aspect of our daily jobs whether it's an E&M service, a procedural service, or a diagnostic service. So AMA and CMS have different definitions but they're very similar at the same time. So with the AMA they define it as a health care service or product that a physician would provide to to a patient for the purpose of either preventing diagnosing or treating either an illness, injury, disease, or its symptoms in a manner that would be in accordance with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient, physician, or other health care provider. Now with Medicare this is the most common one that we see quoted. So they of course state medical necessity of a service is the overarching criteria for payment in addition to the individual requirements of that CPT code. They further state it would not be medically necessary or appropriate to bill a higher level of evaluation and management when a lower level of service is warranted. The amount of documentation should not be the primary influence upon which a specific level of service is billed. That documentation should support the level you are reporting and again the service should be documented during or as soon as possible after it is provided to the patient. One thing again to point out there, so previously with our prior to the 2021 changes they made to the office services we knew with the hospital it was still following the 95-97 guidelines where you are having to select the components whether it be history, exam, medical decision-making. So really what they were pointing out in that area is if you are meeting a comprehensive history, a comprehensive exam, but a moderate level of medical decision-making it would not be appropriate to report that highest level because your overall medical decision-making did not warrant that. So moving into 2023 we know our history and exam components are now going to be not calculated in our overall leveling. It will truly either be that medical decision-making or time-based reporting. So some highlights of the 2023 changes from the AMA. So the observation E&M services were deleted and the inpatient services were revised to now include both observation and inpatient services. This includes our initial admission codes that 99221 through that 99223, our subsequent codes that we sometimes refer to as the rounding visits. Those are our 99231 through the 99233 and it also affected our discharge codes, the 99238 and 99239. So those were all revised to include both observation and inpatient services. The consult services were retained and the guidelines were aligned with the medical decision-making guideline updates. Medicare, however, did not change their guidance on reporting these services. They are still not allowed by Medicare for reporting. You would just crosswalk the service to the appropriate E&M depending on the place of service the patient's being seen in. There were some differences with the AMA and Medicare on reporting the prolonged services. So Medicare did add their own G codes. Nicole will be covering the time-based reporting later in today's presentation so there will be more details covered with that. For the home and resident E&M services, they have some changes also with some deletions and revisions made. If you report these services, you can review those updates in detail. Along with the nursing facility E&M services, those also were revised. Nicole and I actually did a webinar back in August when the AMA released all the 2023 updates. So if you do report in those two areas and you need a refresher on that, you can go to the MedAxium Academy and find that recording and listen to that presentation. Again, it was given back in August. There would also be a copy of the presentation so if you needed to download the slides. And then finally to cover the emergency department reporting, there were no changes made with adding any time-based services as an option. So these services are truly still based on that medical decision-making when you're looking at selecting the appropriate level of service. Touch up on some highlights now of the Medicare physician fee schedule final rule. We know Medicare and the AMA have been continuing to work together to try to align the guidelines and simplify it really for reporting on that evaluation and management. So Medicare is adopting the AMA changes for the 2023 services. Again, Medicare did not agree with the AMA on the prolonged services so they created their own new code. One area of importance to highlight, Medicare has been receiving a lot of feedback from the community on the APP taxonomy assignments with our subspecialty designations and cardiology. Medicare is looking at options to better align this with the best clinical practices but as of now they are retaining the APPs are their current own designated specialty so there is no changes that they're making currently with a separate subspecialty taxonomy assignment. So the APPs when they get credentialed, they have their own taxonomy assignment showing that they are an APP. CMS did cover in the final rule details about the 8 to 24-hour policy. I'll touch up on this further in detail with you in an upcoming slide. And then again, just a quick revision or update here. There were no changes again to the consult service reporting from a Medicare perspective. They will not accept your consult code so that's your 99242 through the 99255. So you would just crosswalk those to the appropriate service provided pending their place of service. So with the revisions to the initial 99221, 99233 services and then your subsequent 99231 through 99233, the initial service reported criteria, those have been adjusted. Prior to the 2023 upcoming changes, the guidelines indicated that the initial hospital service was used to report the first hospital inpatient encounter with the patient by that admitting provider. We know with Medicare changing their stance years ago on reporting those consult services that there were some updated guidance implemented to allow other providers to also report the service. But then that true admitting physician would have to append that modifier AI. With the 2023 changes, the language was revised with this extending the definition of the first encounter to incorporate that observation status. The admitting physician language has been removed and the criteria relating to physicians in the same specialty and subspecialty group practice have been added. The true admitting physicians should still append that modifier AI if the carrier requires this. We do know Medicare is a carrier that requires it. So again, you're going to want to check with all your big payers across your practices to see what policies they have implemented. No one area is the same as another. I can tell you there's certain carriers in Florida commercial carrier wise that will only allow one provider to report that initial service. So again, there's no way to answer this for each individual person that may ask this question. It's just best guidance we can give is to contact your carriers directly. Again, to highlight the initial visit, it is defined as the patient has not received any professional services from the physician or other qualified healthcare professional or another physician or qualified health, or I'm sorry, of the same exact specialty and subspecialty. So that's factoring in the subspecialty designations, which we know in cardiology, we have quite a few. So it's saying during these inpatient observation or nursing facility admission and stay. So it would be the same stay. You would only report it once depending on the subspecialty designation. And then again, your subsequent that's a provider that is basically just seeing them following that initial visit on another day. Lots and lots of questions on this place of service and how to report it. So again, with the release of the changes that we know are coming, that place of service should be reported to what is designated by that patient status in the facility. So nothing has really changed in this area. If they are inpatient, then of course you're going to report that appropriate inpatient place of service. Same thing if they're observation. Now there are times where the patient may come through the emergency room, their pin and observation status. And then a few days later, they're then changed to an inpatient status. So whenever you're seeing that patient at the time you're seeing them, that's the place of service you report. And then if it changed, if it changes and goes to a different place of service status, then you would report that appropriate place of service on that date. Continuing with our inpatient observation services. Again, this is an area of confusion. We are getting a lot of questions with this particular guidance here from the AMA. So what they're stating here is when a patient is being admitted to the hospital, whether it be inpatient or observation status, in the course of an encounter in another site of service, the services in the initial site may be reported separately. Modifier 25 would need to be appended if supported to show a significant separately identifiable service was provided the same day. Now with Medicare, we know that they have not changed their guidance on this policy. They will only allow one E&M service per calendar date by the same provider or specialty. Now a scenario that we can talk about real quick that we could see commonly in our cardiology space. So we say we have a patient that comes into the office setting for a follow-up, and they're having a significant exacerbation or progression of their CHF. Provider sees the patient for a full office visit and decides that the patient needs to go to the hospital for admission for IV Lasix. So now you have a provider in the same group, same specialty that's already in the hospital, so they're going to see that patient for that admission. They're going to do an H&P, but makes no changes in the plan of care from the provider that saw them in the office setting. So looking at this scenario and the AMA guidance here with the Modifier 25, think about it. Is the Modifier 25 truly supported in this type of scenario? It wouldn't be because it's not a separately identifiable service. It's the same plan of care by the same providers of the same specialty. So in that case, you're truly only going to report that one E&M service for that, you know, patient being seen that day, whether it be you choose to report the office service or that hospital. And again, Medicare has not changed their stance on this, so it is truly only one calendar E&M per calendar date. So again, best advice we can give you with this AMA guidance coming out is to check with your carriers again and see if they're going to allow you to report two E&M services on the same day with a scenario like this where there may be seen in the office first and then they end up going over to the hospital for admission. You're going to want to check with your payers and see if they're even going to allow it. This is just a snapshot of what the 2023 codes will look like for our initial hospital services. The AMA did revise the time-based reporting assignment for these services. So the amounts were increased from what 2022 assignments are. So like the 99221 assignment for this current year is 30 minutes. For the moderate, it's 50 minutes and then high is 70 minutes. So you can see there was a little bit of an increase with the time allowed, but with the time-based reporting now, remember it's aligning with the 2021 guidance. So now we can count some of that non-face-to-face time that spent reviewing patient records, any time that may be spent talking with other healthcare providers or ordering additional testing. So that's why some of the times were increased to account for some of that non-face-to-face time provided. Here's a snapshot again of our subsequent services. Again, the time allotments here were also increased from what we currently have assigned for 2022. So again, Nicole will be covering the time-based service option reporting later in the presentation. Some observation general guidelines. So areas to point out here, there must be a minimum of eight hours to be even considered and to be an observation status. For 2023, the E&M services now include both observation and inpatient in the description of that CPT code. You will need to use the appropriate place of service to report the service accurately. Patients should be designated and listed as either being an observation status or that inpatient status. It is not necessary though that the patient be located in a special observation area that is designated from the hospital. And then again, Medicare's policy on the eight to 24-hour rule will remain in effect. Again, I'm going to actually cover this with you next. All right. So this is what the eight to 24-hour rule looks like. So if the length of stay is less than eight hours and they are sent home same day, the guidelines instruct us to report only an initial hospital service only. Now, if it's greater than eight hours and they are sent home same day, the guidelines instruct us to report that admission discharge service code same day. So there's special E&M service codes that would account for both an admission and a discharge if it's done same day by that provider. If the length of stay is less than eight hours and they are sent home on a different day, the guidelines instruct us to report an initial hospital service only. Now this could be a scenario where a patient comes in late at night, they then pass that midnight threshold and they're into the next day, but they're still there overall less than an eight hour period. So that would be a scenario with that. And then finally, if the length of stay is greater than eight hours and they are sent home again on a different calendar date, we are then instructed to report that initial hospital service on the date it was provided, and then you would report your discharge service on the date that was provided. So these were those admission discharge same day codes I was just talking about. These require two or more encounters on the same date of which the encounter is an initial admission and then another would be a discharge encounter. If the patient is again admitted and discharged at the same encounter and there's only the one note, CPT instructs to only report the initial visit. So the hospital inpatient or observation discharge day, so our observation code we previously had for discharge, the 99217, that is deleted for 2023. And now these were revised to include both inpatient and observation discharges. These are time-based services, so it is important that the time be documented when your provider is in charge of discharging. Now if your provider is not the discharging provider, but patient's going to be discharged that day and your provider is doing his subsequent rounding visit, you would just report that appropriate E&M service instead. From an AMA perspective with consult services, so their guidelines state, first let's define it, they say it's a type of evaluation and management service that is provided at the request of another physician or qualified healthcare professional or an appropriate source to recommend care for a specific condition or problem. Secondly, a consult that is initiated by a patient or family member and not requested from a physician, qualified healthcare professional, or other allowed source would not be considered a consult service. So again, it has to come from a physician, qualified healthcare professional, or appropriate approved source to be counted as a consult. The consultant's opinion and any services provided or planned should be communicated with and by a written report to that requesting provider. If those three, if these three bullets are not met, then realistically you cannot report that consult service. You would just crosswalk it over to an appropriate E&M service depending on their place of service. These are our consult services moving into 2023. You'll notice that there's only four now. These are for our outpatient office service. So that 99241 was deleted and that went in line with the AMA deleting in 2021 that 99201 service. So that's just them aligning that. Those were the least reported services. So the AMA did not see any use for them anymore. So now we truly just have four levels of service depending on that medical decision-making being straightforward, low, moderate, or high. Or again, if you're looking at that time-based option with the time allotments that are assigned. Again, these are for our outpatient office service. These are inpatient hospital consult services. Again, you'll notice that 99251 has also been deleted. This again is just staying in line with all the AMA revisions. It was probably one of, not probably, it was the least reported service if it was even reported at all. So again, we have our straightforward, low, moderate, and high levels now. And again, the different time assignments depending if you're looking at that time-based reporting. For emergency department, these are only reported when the patient is provided services in the emergency department setting only. Nothing has changed with this for 2023, so this is already an established guidance. You will need to check again with your payers on if they allow this service to be reported or not. From a Medicare perspective, they do want these reported if the patient is only in the emergency department setting and they are never admitted. The AMA and Medicare are maintaining the existing principles that time cannot be used as a key factor for selecting the level. Only the medical decision-making can be used. And the reason for this is that most providers in the emergency department setting are moving from room to room multiple times, seeing many patients, and then they'll come back and they'll see the patient again. So it's really impossible for them to accurately account for any time-based reporting. So this is why the guidance right now shows medical decision-making is your only level as far as selecting. The existing codes were maintained for 2023, so there's no code changes itself. And then finally, if you have a rare scenario where you see a patient in the ED and then they're never admitted but they are in the emergency department, they then become critically ill after you've already seen them and now you have to see them again and they're meeting that critical care definition and their note supports, then you can report both of those services same day. You would just need to append that modifier 25 to one of them. Again, here's what our codes look like. Again, no changes. Guidelines are staying the same. Just that medical decision-making overall, those guidelines are aligning with the AMA and Medicare. So other than that, no code changes here. All right. So I will hand it over to Nicole now. She's going to talk about medical decision-making and time-based services. I'm here, Jamie. Okay. I'm just typing a question. All right. All right. Looks good. All right. Thanks, everyone. So we're going to dive into determining the E&M service level by talking about medical decision-making or time. So similar to what Jamie talked about in all of the guidelines, there was a comprehensive restructure. So when you look in your CPT book and the guidelines, you're going to see a lot of green because there were a lot of revisions. And a lot of that represents all of the changes for our inpatient observation, ER, all those services that occurred. So that's what a lot of the green text updates revisions are. There was some addition and clarifying guidelines and some minor editorial revisions that we'll talk about and some clarifications on time as well. So we will go through that as we talk through the medical decision-making table. When we look at history and exam, the same as our office and outpatient services, now a medically appropriate history or physical exam would be what is required, and that's determined by the provider. There's no change. The care team may collect the information on the history, for example. However, the provider still has to review and acknowledge that they reviewed that. And I think the most important thing is, regardless of the history and physical exam, it's not going to determine that level of E&M service. So our guidelines are aligned with our office and outpatient services, and maybe we'll see not the eight or 10-page notes. So we'll see how that's determined as we move forward. When we're selecting our E&M service, it's based on medical decision-making or time. So let's talk a little bit about the levels of medical decision-making. There are four types of medical decision-making. This has not changed, so straightforward, low, moderate, and high. And when we look at medical decision-making as we go through the table of risk, the medical decision-making has not changed that it requires two out of three elements to select the medical decision-making. So when we look at our different elements, the first is the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of patient. So it hasn't changed. In order to determine your level of service, you have to meet two out of three of these medical decision-making elements. Problems addressed, I think it's important to also revisit this definition in education of your providers. And this also goes to capturing all of our diagnostic codes and services. If you're looking for risk adjustment coding and the focus being on diagnosis coding, this definition is very helpful and supports that concept of risk adjustment as well. If a problem has to be addressed and managed, it can't just be listed in a problem list. So we know we have these long problem lists that are pulled over each time. Any of the problems that are listed must be addressed within the documentation or managed by the provider. So if I list diabetes but I don't have any documentation to support I addressed or managed, evaluated, treated anything for diabetes, then that diabetes cannot be counted as a problem addressed. So they just clarified this that that also applies to, and it's that last bullet, for hospital inpatient and observation services on the date of the encounter, which may be significantly different than on the admission. So you think about that if you're billing the initial admission and you're billing your subsequent visits, the problems have to be addressed in those subsequent rounding visits in order for them to count toward your medical decision making and the problems addressed or managed. Complexity reminders. We talked about risk adjustment a little bit. Capturing the comorbidities and underlying diseases. Again, you want to be sure that they are addressed and the presence of them alone does not increase the complexity if they're not addressed. The medical decision making is a guide to assist, so it's not a black and white table. The examples may be more or less applicable to specific settings of care. This comes directly from the CPT guidelines. Final diagnosis does not in and of itself determine the complexity of risk. Extensive evaluation may be required to reach a conclusion that may be just signs and symptoms. So when you really look at a highly morbid condition, if the patient is having acceleration of signs and symptoms, those types of things, based on just a diagnosis, we're not determining that level of risk. It's truly by what's supported in the documentation on that patient's acuity, the level of risk, the problems addressed, and the treatment, diagnostics, testing reviewed and requested. So we're going to start and go through the table. This is straightforward. I would say we probably don't see any patients in this area, maybe occasionally, so we're not going to spend a lot of time on that one. For our low-level services, this would be low medical decision making. The bolded items under number and complexity of problems addressed at the encounter, these were some changes that were made to the table for next year to support the hospital service aspect. So one stable acute illness or one acute uncomplicated illness or injury requiring hospital inpatient or observation level of care. It's interesting when you think about that in the hospital setting and what would represent low medical decision making on the problems addressed, and you think about your initial visits, talking with your providers to get some examples on what may fall into this category, because a lot of these patients, as you can see from a risk of complications of morbidity and mortality, it's very low. Also, they only have to meet one requirement out of two in our data review, so it's a combination of test and review of documents or either an assessment with the independent historian. So this would be our lower-level services. This is pretty straightforward, and again, the only additions here were to support hospital services, and they're bolded there. All right. So when we talk about a level one rounding visit, I know many of you know we see these as we look through our rounding notes on multiple days. So what may be a scenario? Well, you may have some HPI where it says no chest pain, palpitations, shortness of breath, or swelling, and then your medical decision making may just be blood pressure improved, edema improved, negative INOs. So this is a very straightforward low-level one office visit, so this could be a scenario that would fit that category. When we talk about our moderate services, a majority of our patients fall within this category, either moderate or high. That we'll review in a bit. For our moderate category, there were no changes in this area. There was some clarification in a few of the definitions, and we'll touch on that, but really when you look at this area of medical decision making and applying our hospital services to this, it's the same as our office and outpatient chart. This is just some of the clarification that we see, because as we know, under our risk examples of moderate medical decision making are prescription drug management. So there's been a lot of questions around that. The AMA did post on their website a FAQ document. It's not very many FAQs, but there are a few out there. I expect that the first quarter of next year we'll be having another E&M session, probably in February, going through what the different carriers are doing and further clarifications from National CMS and the AMA, but this one I thought was relative to what we do in our normal routine of looking at E&M services and prescription drug management. So it was discussed and understand that it was intended for clinical judgment by clinicians when it's related to medical decision making, and they talk about elaborating on what constitutes prescription drug management. Is it enough to simply review the medication list? Does there need to be management of a condition? Does a provider stating there's a moderate risk or an over-the-counter medication enough to justify a moderate level of risk regarding patient management? And this was the AMA's response, and I think this is what we all have to remember. There's no blanket guidance for services to represent specific risk. If they made it black and white, we think it would be easier. I'm not sure. I think there is no blanket guidance. When you look at if a physician is responsible for assessing and documenting the level of risk of the services to be performed, including medication management, prescription, or over-the-counter, based on that patient's risk factors and the risks typically seen with the drug. So for example, if you're doing an NSAID in a person with kidney disease or an anticoagulant, this is of greater concern than most prescription drugs. Simply reviewing a medication list does not necessarily constitute prescription drug management, and they talk about that the E&M work group will continue to monitor questions and consider clarifications in education. This is not something new for us. So if you just have a medication list and there's no documentation that there's any type of medical management of that medication or there's any review of that medication, and I know we're going to go to if you just check a box saying I reviewed the medication list, I think that's what this is pointing to. If your physicians still document continue hyperlipidemia, continue Lipitor, that's documentation of medication management, prescription medication management. If they review certain medications, do refills on certain medications, what this is referring to is the simple I checked the box or I have a medication list documented in my note. So I think it's important. There's not a change here for the physicians. Prescription drug management would be management of any of their prescription drugs and documentation of that. When we talk about surgery for elective, minor surgery, major surgery, this they did a publication of that's really not changed, but they further clarified minor, major, elective or emergency surgery. So for minor or major surgery, I think the important takeaway here is that these are not defined by a surgical package. That probably would have made it a little easier for us, but they did publish in the guidelines that it's not based on the surgical package of a code. When you look at the elective or emergency management, elective procedures and emergency or urgent procedures, I think we all know what that is. An elective procedure is normally planned in advance, meaning we probably see them in the office. We're scheduling for elective procedure as an example. An emergent procedure, there's minimal delay and that patient's being stabilized. It's interesting because the clarification here, both elective and emergency procedures may be minor or major procedures. So that's truly determined by the provider and that's how the guidelines read. In this next statement, they cover risk factors of patient or procedure. What I will tell you, when you read the sentence, it says risk factors are those that are relevant to the patient and the procedure. Evidence-based risk calculators may be used but are not required in assessing the patient and procedure risk. It's important to know that when they say relevant to the patient and procedure, this is individually relevant to that patient and their particular increased risk for a procedure. It's not the normal bleeding, any of those things, just from a procedure that may occur. It's that particular risk to the patient. That is not something new. I think the piece for everyone that's been new is it's not just based on that surgical package. So if the physician determines that a procedure is a minor or major procedure and documents it as such, they still have to document, establish, and support that risk of that patient for that particular procedure. All right, here's a scenario that may support moderate decision-making. Patients sitting up in bed, very comfortable, nasal cannula in place, IV Lasix overnight, patient denies chest pain, is improving, diuresing well, and then I get to my assessment and I have acute on chronic heart failure, improving, IV Lasix decreased to once daily. I listed my cardiomyopathy, my CAD, stable, continue aspirin, hypertension, controlled, and continuing metaprolol. I have an elevated troponin and med noncompliance. So when you look at this, it would represent right off from looking at this without overanalyzing in the table of risk, I know that there are two or more stable chronic illnesses and prescription drug management, and it would meet that moderate level on this patient as they're improving, doing better. So that would be our level two. When we talk about the medical decision-making and our high level of service, the bolded categories in the high risk of morbidity under a risk of complications, they added or escalation of hospital level care or parental controlled substances. So those were added as part of the 23 updates for our hospital services. So when we look at moderate versus high, there's no change to if it's a major procedure with identified risk factors, and you can see it says decision regarding elective major surgery with identified risk factors, decision regarding emergency major surgery. Those have not changed. It's still, when you go to moderate, elective major or minor surgery without identified risk factors or, you know, it's no different than what we've been using in our office and outpatient setting. The key of that is what does that documentation look like? And it's not just meeting, remember, one area of medical decision-making. Even though I meet that the patient is at an increased risk and the physician determined that it's a major surgery or procedure and they have risk factors, I still have to meet my medical decision-making either in my number and complexity of problems or my data. So even if I meet it in one of these based on that patient's risk, on that day of the encounter when I'm seeing them, I still have to meet it in one of these categories. So I think it's important to remember as you're determining medical decision-making that it's two out of three, so don't get stuck in just one of these categories. Look for your two out of three categories, and if you're struggling to find a second one, then that's when you're looking, and you're looking for the good documentation and correct documentation, providing that feedback to your physicians when you're looking at that information. Drugs requiring intensive monitoring, just a couple of things here. Not much has changed on the side of the clarification about intensive monitoring. I think this is a call-out more around monitoring maybe does not have to be extensive monitoring, but they still have history and exam does not qualify as monitoring. Monitoring, you generally have a lab test or imaging or physiologic test performed, and the monitoring affects the level of decision-making in an encounter in which the patient is considered in the management of the patient, sorry. So what they're saying is the monitoring impacts that level of service on the date of the encounter for the management of that patient at the time of the visit. So again, this is one element of medical decision-making. So when you look at this, looking at the documentation and determining if it meets drug therapy requiring intensive monitoring, you want to be sure you have that other level of medical decision-making in order to meet two elements out of the three. All right. Another clarifying question from the AMA that was available. In regards to rounding visits, how will lab and imaging studies be counted for E&M in terms of the amount and complexity of data for daily standing orders pertinent to their hospital stay, and then a similar question was does the addition of the paternal controlled substances count as high complexity only on the day of the encounter where they are initiated, or will it also count on the subsequent days the patient continues to be on those medications for the controlled substances? So let me read the answer here. For rounding visits, subsequent care codes for inpatient and observation services, so that's our level one to level three rounding services, they've been revised to include medical decision-making levels for each subsequent day the patient's condition and any standing order may be considered when selecting the appropriate level of medical decision-making required in order to support the code. The table that is current for E&M service selection is the best place to review this information, again, not black and white. In the example regarding the perineural medications, medical decision-making occurs on the day the medications are ordered and initiated. If the provider is overseeing and monitoring the medication and determining whether or not to continue, it may be counted on subsequent days. This would be an exception if another provider is managing that aspect of care. So as each patient's condition and their individual clinician judgment providing treatment varies, this will be resolved on a case-by-case basis. So, you know, what this is saying is there's no blanket answer to this. If on the initiation of the controlled substance, we know that counts as part of the medical decision-making, if on subsequent days the documentation supports that your physician is managing that aspect of their care and they are making changes or continuing that medication or monitoring for any side effects, pain control, those types of things, and that's documented in a rounding visit, then that would support it. Just listing that medication, again, is not going to support this. Medical decision-making is what is the physician doing, what is the provider doing, how are they monitoring the medication, and determining to continue that medication. And that goes for standing orders as well. If it's a standing order and there's no change, no reference to that on the subsequent day, how can it count towards your medical decision-making? And again, I think that'll be on a case-by-case basis. All right. So this one I put up, and I know it's probably going to generate some activity of questions here, but, you know, let's see if you think this could be a level two or a level three, because this is our reality when we're looking at these initial inpatients or observation care codes. I'm not going to read all of this information. I'm going to just hit the key components, but know that there's a comprehensive note here. This particular patient came in, he had a history of a stroke with some weakness. He was admitted to the hospital because he was having pain in his hip because he had a fall, and it goes into the details about his fall. On his arrival, his blood pressure was significantly elevated. He was transferred to another hospital for further evaluation. When he got to the hospital, he had an elevated troponin, and cardiology was consulted. He had, they reviewed a CT of the chest. They go into further detail about the patient's symptoms, their baseline, their stability, edema, et cetera. They talk about the patient admits falling asleep at the wheel. He's pending an outpatient sleep study. Then we get to that assessment and recommendations. For his assessment, accelerated hypertension. Then he talks about his elevated troponin. Now, remember, over here, he talked about on his blood pressure was significantly elevated over 200, so he's got that accelerated hypertension. He's got an elevated troponin, talks about no chest pain, EKG, echo, reviews, talks about the CT scan again. He doesn't suspect ACS at this time. Talks about hypertensive heart disease, the history of the stroke, the urinary tract infection, hypokalemia, and the obstructive sleep apnea. For recommendations, they're going to monitor him on telemetry, have, start some medications, monitor his blood pressure. He was put on Lobanox. They're going to stop that for now. They're going to focus on blood pressure control and symptom monitoring. He's going to have a stress test tomorrow, and his pain control is by the primary care team. On this one, the reason I put, is it a two or a three, is because when you look at this, this patient has the accelerated hypertension, so they have a worsening of an existing condition or an acute condition. And then also, when you talk about he independently, did he independently review the CT scan? I don't know if that's totally clear here. He could be looking at a report of a CT scan, but he talks about that, you know, if he discussed this with the previous hospital, those types of things could bring this to a level three. Now, do I believe this necessarily would be supported as a level three based on the risk of the patient? It could be. This is where coders are going to differ. That's why it's so important to look at the documentation in its entirety. For me, I would say this would probably be, you know, the patient's having this elevated blood pressure. He's at risk. He's already had a history of a remote stroke. You know, he's on blood pressure control and monitoring. This could be a three for me. Would I say I would like to see them talk about that they independently reviewed the CT scan? Would they look at that they talked to the admitting hospital and had their care transferred over and gathered that history from someone independently to meet two of the data criteria? But could you meet this on the problems addressed and the risk of the patient? And I think that's what we each have to look at as you're looking at this and providing feedback to your providers. Two out of three of the medical decision making components and getting those key areas of documentation. Now that we don't have to focus on do I have my comprehensive review of systems? Do I have my comprehensive exam? Let's focus on what matters in that documentation and deriving that level of service here to really determine if this is a two or a three or where you would fall in this. So this is just a scenario for discussion purposes only. For a level three rounding visit, this is one that supports complexity of the problems addressed and the high risk morbidity just as we talked about potentially on the visit before. It talks about the patient has a chest x-ray that's worsening for pulmonary edema, has worsening anemia, they are discussing the case, they've ordered some studies, those types of things. He's going to start back on a heparin drip to continue monitoring the signs of bleeding and this would support a level three. Again, scenario based, the complete documentation is not here, but this would be some of the key points you're looking for to support that level three rounding visit. Right, so from a recap perspective on medical decision making, which by the way, we don't see a lot of providers that use time as the driving factor for medical decision making. Now that this is transitioning to our hospital services, it'll be interesting if we see more use of time in the hospital depending on the complexity of the patients. But usually we are doing this medical decision making on our office and outpatient patients and prior, you know, what we've been doing in the hospital has been truly based on medical decision making. And the key is, am I supporting two out of three of the medical decision making components to meet my level of service? So let's talk a little bit about billing based on time. So when we look at time and how it's counted, the 95-97 guidelines, I don't think we even have to talk about those anymore, totally gone away. And I'm sure we'll see our E&M guide updated and all of those things. But what's included in total time the day of the visit? It is the physician and APP time only. It's preparing to see the patient. It's obtaining and reviewing a separate history, performing any exam, counseling, ordering of test meds, etc., referring and communicating with other providers and documentation of that clinical information. What's not counted in time? The clarification here was that travel and teaching that is general and not limited to discussion that is required for management of the patient. So when we look at our teaching service providers and we look at travel time, that's not included. And this is not new performance of other services that are reported separately. So if you're independently interpreting a echocardiogram, for example, and you're billing for that professional interpretation, the time you spent reviewing that echo and doing the interpretation does not count towards the level of E&M service. If you're billing transitional care management or chronic care management, in addition to a E&M service level, you would not be able to count time that's being used for other time based services. This was something also that was interesting when you look in the guidelines for CPT. CPT has a blip about split shared services and addressing questions. I think it's important to understand the difference between split shared. So in CPT, they talk about it relates to how total time is counted and not who reports the service. And it both must have face to face work. And CPT does not address who reports. So what they're basically saying in CPT is they're not determining who is the billable provider based on time or face to face work. But when we look at CMS, we know that the concept is there and it continues into next year that it's based on who performs the substantive portion of the E&M, if that's history exam or medical decision making, or if it's done on time. It says proposed there because this was a previous slide, but they did approve for next year that medical decision making may still be used on who documents the substantive portion and time. So it's not going to time only like we thought it would. Medical decision making may still be used. So this is the time category in the CMS final rule. If you can read and go through the comments and the responses back and forth around a lot of these areas in the final rule for Medicare, they talk about that it wanted they wanted it clear to say must meet or exceed the time. So when you look at the total time on the date of an encounter, it must meet or exceed the time. So these are the times as they're relative to our initial hospital observation CPTs and our subsequent inpatient observation CPTs. And then we'll talk a little bit about prolonged services. So for prolonged services, there were some deletions of codes. We also covered in that Jamie mentioned our previous webinar with some clarifications around prolonged services. We're not going to get into the nitty gritty here, because as we know, from a CMS guideline perspective, which is relevant to our Medicare Advantage plans. And it'll be interesting how commercials interpret this. But basically, both for office prolonged services, for hospital prolonged services, Medicare has adopted their own G codes here. So when you look at the varying prolonged service codes, we have codes that are in CPTs such as these that describe before and after direct patient care, and they have a time threshold. These are not covered by CMS. When you look at these codes, these are the ones where they have a G code for Medicare. And then also the time thresholds for Medicare to some of the prolonged service time ranges. When we looked at our outpatient services that we talked about, you want to be sure that you're consistently following that. But I'm not sure how many of us are really billing prolonged services in the office setting have not seen through many audits that folks are doing it because those encounters are generally based on medical decision making and not time. But from a CMS perspective, these services are not covered by Medicare. So the 99418 is the new code that they added for our hospital services and CPT. They are listed in the Medicare final rule as a non-covered service. And basically, all of the durations, tables, and everything that support this, I would say, depending on how further clarification comes out from your commercial payers and if you're billing based on time and you're going to use prolonged services, really understanding your payers and how this will be applicable to certain patient populations and having some standards in your practice that are helpful for both your providers and your coders to understand what would be falling into these categories. These are the CMS time thresholds to report other E&M prolonged services. So like we talked about the G codes that they've added. So you can see that the G code, if you're reporting an initial observation visit, a 99223, and you're reporting a G0316, the time threshold is 105 minutes and it's the date of the visit. Now, will we see some of that in the hospital based on cumulative time throughout the day? How we're going to utilize that and operationalize that? I think we're still working through that in scenarios. I'm hopeful we'll get some classification, clarification of this as we go into the new year. But prolonged services, any information you get from your carriers and how you're implementing this in your practice, please share it on the listserv as many folks will continue to look at this area for if there is an opportunity to be able to bill for some of these services and how we would utilize this in the hospital system. You know, in the office, we know that a lot of the time is not spent in those extensive visits unless you're in some subspecialization like fetal medicine is one I've seen it used in. But in our hospital services, this could be different. But again, date of the visit. So how do we utilize this? And what's that going to look like in calculating that time? And then you add that layer of split shared services onto this and really how we look at this. I think some further clarification and having some examples early in the new year will hopefully be able to provide for you. All right. So tomorrow is our last day of boot camp, and it's going to be about coding and reimbursement of our office-based labs and our ambulatory surgery centers. So Jamie and I will be back with you tomorrow to go over that. We do have some time for some questions. So I know there's been quite a few coming through and we've been answering. I see someone mentioned to talk about the time rule again as related to teaching. As we talked about, they clarified in CPT that the time utilized for teaching cannot be calculated as time for a level of the E&M service. So you cannot count that as part of the time if the physician is truly teaching the patient during that service time. Jamie, do you see anything? So yeah, like Nicole said, we answered a lot throughout the presentation. We will still compile all those questions and answers into that document, and we will get that uploaded to our website and our MedAx Academy. So that way you will be able to download that document to refer back to as a reference. There's some questions that are a little bit more specific, so those we will answer offline. I will say there's a couple coming up about split shared and total time and physician and APP time. If you go back to the split shared guidelines, and this isn't addressing one particular question, but just of note to mention, when you look at if you're billing split shared service based on time, it's the provider who spent greater than half the time or more than 50% of the time. So you would be calculating your time for that day of the encounter. And if the APP spent more time than the physician, and you're billing based on time, it's billed under the APP. If it's the physician who spends more time, it's billed under the physician. It requires documentation of the exact time spent, doesn't have to be clock time, can be the time based on, you know, if I spent 30 minutes or the doctor says he spent 15 minutes. And I think that's what we're going to have to get used to in order to bill that. Another question that's come up a lot around our discharge service codes. So our 99238 and 39, there is no substantive portion to a discharge. A discharge is a time-based service. So for discharges, what determines the level of service is time. So there are several codes that are determined by time only, and discharge services are one of them. So you don't have the option for split shared services to bill discharges based on a substantive portion. It has to be done on time. And a reminder, only the attending physician bills the discharge. So if you're not the attending admitting physician, then you may not be billing the discharge. You would be billing a rounding visit potentially, which does have a substantive portion or based on time. We've had a few people ask about if we have a cheat sheet for the E&M services. So what MedAxiom is doing currently is we are using the AMA guidelines. So they print either in the book or if you have an online platform you use, we're using that table that they have currently. Some of the Medicare contractors have updated their websites with the 2021 changes. Obviously they'll update it further with the 2023 stuff, and some of those sites will actually guide you through coding a service. So you can hit in where your condition falls under, under your problems addressed, any data points that would be supported, and then your overall risk, and it will actually calculate your level of service. So that is currently what we are using as of right now. Someone was asking if you don't document any time, and can we just bill the low level discharge? I would not recommend that because it's a time-based service code. When it's a time-based service code, if you look at CPT, it does require you to document the time. It can be total time, but it does require you to document the time. When the physician and the APP document the same amount of time, I would just tell them don't do that. That's Nicole's opinion. That's not an official opinion, but I mean, how are you going to choose? You can't just choose, and then you have two legal documentations for that day. So within your program, you have to determine how you're going to bill split shared services and how that's going to be defined. But if both are documenting the same amount of time, to me, that sends up some red flags. If they request documentation for that day, it's part of the medical record. And Nicole's personal opinion is that I just would not let that be part of a standard within my program because I think that just opens the door for some risk. Yeah. Another question here, how is critical care time reported differently for CMS versus CPT? So the time assignments in our CPT book are what the assignments are. When you're looking at critical care as a whole, are they meeting that critical care definition in that moment of time? So that's important to point out. We as educators and auditors, we sometimes will look at a critical care note and it'll show the patient's improving, they're sitting up and having a meal and discussing everything with the provider. In that moment of time, obviously those types of scenarios would not meet that critical care. So there is no difference as far as that time assignment, if you are looking at reporting those critical care services. Yeah, I would add, like Jamie said, it's important to understand critical care is not only driven by time, it's definition and treatment. So they look at all three elements for critical care. So you want to be sure your documentation is solid for that. And we have some questions. So our provider-based clinics, which are designated as outpatient hospital clinics, you can bill split services in place of service 22, or if you're a 19, some are designated as a 19, split share does apply. If you're billing E&M services in your office setting as place of service 11, incident two is the concept, not split shared. So you want to be clear on split shared versus incident two when it comes to Medicare guidelines. Somebody here also asked if that modifier FS is still in play. Yes, there's been no changes to that for a Medicare perspective. You are going to want to check with your commercial payers and see if they want the FS modifier appended on your split shared services. Some of them do vary, obviously, across the country. So again, just check with those payers. Let's see. Quite a few coming in. Let's see. There was more clarification on time teaching. Like I mentioned on the time slide, teaching is referring to actually teaching service physicians, providing teaching to residents, fellows. That time cannot be calculated as part of the time, their teaching time, not patient teaching. Patient teaching, counseling, coordination of care, all of that is included in the time. Critical care services can be split shared now. There's a lot of caveats to that, but they are able to be split shared. And usually that comes into play when billing for that first initial 99291 critical care service. Here's one. I noticed a question about coding diabetes on a claim if not addressed, and the answer was no. Wouldn't you code the diabetes for HCC coding, but it would not count towards your level? So when you're looking at risk adjustment reporting, the addressing of the condition is still required. So you can't just simply code off of a problem list without seeing that condition addressed within that note. It could be documented in their history component. So if that's the case, it's not addressed in the assessment and plan per se, but the physician does talk about their diabetes, how it's currently managed, whether or not it's stable, those types of details, then yes, you could still report it for HCC coding purposes, but you wouldn't count it in your overall level. But if it's just simply listed in the note and that's all you have, you can't code it at all. Correct. I remember our little acronyms for risk adjustment. What is it, Jamie? MEAT. It's an awful acronym, but they have to address it, just as Jamie said. I can tell we need to have a split shared as part of our February when we go through some scenarios, and split shared is not an easy straightforward, so I see we have a lot of questions on that. We'll definitely look at those. Here's one, Jamie. Did we speak to the tests that are performed or interpreted by the cardiologist not being able to count as data in the medical decision making key elements based on separately billable tests? Do you want to take that one, Jamie, or do you want me to take it? I don't remember which one it was. Sorry. I'm still going through the questions. That's okay. I can do that. So it's if your physician is interpreting a study and billing for that interpretation, it cannot be counted towards the medical decision making of that encounter. Now the day that they order the echo, or they order the test, it can be counted as ordering of test. But if it's an interpretation and the patient comes back and he puts in there the interpretation, that cannot be reported as part of the medical decision making. Did I get that right, Jamie? Yes. All right. I see one question here asking if you're reporting a 99214 established moderate office visit along with a 99406, which is our smoking cessation counseling. They're asking which code would get the modifier. So these do bundle together when you're looking at reporting as a whole. So if your level is meeting a moderate, most likely they're addressing other conditions with that 99214. So depending on your carrier, you would append that modifier 25 to your E&M service, and then you would report the 99406. Remember though, those are time-based services also, so you have to have the total time spent counseling the patient with that tobacco cessation. So you would report that also without a modifier. So again, the 99214 would get your 25 if supported, and then you report separately the 99406. One thing that I do want to clarify, and I think we're going to see some clarification on this from our payers, but currently the guidelines state to build an E&M code as a outpatient, office outpatient code set for a consult performed during observation. Someone was asking for 2023, does that mean we build the inpatient code set? I think it depends on the status of the patient and where the patient's located. If it is outpatient, then you're going to build an outpatient office service still. That's not going to change to an inpatient service code, if that makes sense. So if you're the consulting physician and the patient's observation, you're going to build either a 99202 to 99205 or either a 99213 to 15. Here's a question again with split share, like Nicole said, we will cover that early at the start of next year. This question, they're asking if both provider and APP see the patient in the hospital, but they don't document any time, who does the counter bill under? So Medicare did not change any further guidance yet. They were looking at implementing that, going to time-based billing only this year, but they have pushed that off another year. So it is whoever does the substantive portion of that note. So it would depend on what all is documented by both providers and who you would select billing it under. And we have to think about how split share is going to be impacted. And that's why we're saying, you know, and having some additional time to go over split shared and get into detail, because now the level of service will be determined by medical decision-making. So the substantive portion is not determining the level of service. So how is that going to impact our split shared service leveling of service based on that component and taking the documentation in its entirety and reviewing it? So we definitely will cover that more. But you know, it was definitely a win in 23 that we're going to still be able to use substantive portion and not time. I think that's where it's going to be difficult. For observation services, only the physician who is the observation admitting physician would bill for observation care services. So if you're the consultant, you bill the appropriate code range based on that patient's place of service. Next one, if an NPP documented a high-level medical decision-making and the physician documented the exam, what level of exam would the physician need to document to bill for the split shared as a level 3, as a physician NPI? So again, looking at split shared there, we don't have to calculate the overall history exam for leveling purposes. They have to document a component in its entirety. So did that NPP document any portion of an exam or did the physician do that full exam in its entirety? So those types of things are important when you're looking at applying those split shared guidelines overall. So again, without seeing a documented note, it's kind of hard to answer that in full. We definitely got to a lot of questions. There's still some that we will again review and compile. We'll get everything added into one big document. But tomorrow, like Nicole said, we will be covering the OBL and ASC services. So if you are providing those, we will be covering those in depth tomorrow, or if that's something that your practice is looking at implementing in the future, you know, we're going to give great information on that tomorrow. Yeah. All right. Well, thanks everyone for attending and we look forward to further clarifying E&M services and we appreciate the community sharing any of their guidance that they receive from their payers on our listserv.

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