Hi, everyone, we're going to go ahead and get started on our webinar today, Evaluation and Management Hot Topics. My name is Nicole Knight, and I'm the Executive Vice President of MedAxium Revenue Cycle Solutions and Care Transformation. And I'm happy to be joining you on this topic today. Couple of housekeeping items. So in your Zoom control panel, there is a chat box. This is where you will find a link to access the presentation slides. So you should be able to take that link, and you can download them, they are in PDF, and you can save them to your computers, and there are available in the chat box. The Q&A box is where you can type questions in as we go through the webinar. Just remember, we have a lot of content, and I know this is a hot topic this year. So your questions might get answered as we go through the webinar, but feel free, if you have some questions on topic, to type those into the box as we go through the presentation. 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So what we're going to cover today, we're going to talk about the 23 E&M changes, the aligning of those changes with the 21 guidelines that were released for our office and outpatient services. Going to talk about some key coding and documentation callouts. We're going to look at what some of the MACs are saying. That's our local Medicare administrative contractors. So that's specific to your state and region. And then we're going to cover coding and documentation for split shared services. This is just an update. The most recent map that's available on the CMS national website is from 21, but if you needed a reminder for who your MAC is, this gives you that reminder on when we're talking about the different MACs, what areas that we're talking about, and which regions it applies to. So you know, it was interesting as I did my research on all of the MACs. So I did go to each of the websites, I looked, did some research for this presentation as to what they were saying about the 23 E&M changes. It's interesting because as we could expect, many of the items and services that were outlined in the final rule are still waiting guidance by local Medicare carriers on the directions on many of the changes. What I found was the ones that have blue Xs, they have some updates that are available. The others, I didn't see any updates when I did this research last week. So that changes daily, I'm certain, but just to kind of give you an idea, if you don't see something from your Medicare carrier covered, it's more than likely that we didn't have any updated information. But this statement about the technical directions is on most of the Medicare carrier websites. So we know they haven't updated all of their systems. So what are some of the big picture changes and updates to our E&M services this year? They've merged the hospital inpatient and hospital observation services. They align some of the guidance on admission and consults with current use of our initial service codes. The documentation of history examined medical decision making to determine the level of service is now only medical decision making and time is used on the date of that encounter to determine the level of service. And then they have revised, deleted and made some changes to prolonged services. We're going to briefly touch on prolonged services. I will tell you, as I dove into researching prolonged services, it's pretty difficult to bill for that additional time. As you go through these changes and look at how you're utilizing either medical decision making or time in your programs, I'd be interested to hear feedback on if you are using prolonged services as these changes have been revised this year. What hasn't changed? You probably see this slide on many of our presentations. The AMA defines medical necessity as does Medicare CMS. I think the overarching takeaway from this is that it still remains the criteria of payment and it is the overarching criteria and the documentation should support the level of service reported. And we always have to keep that at the forefront when we are documenting on our patients and having that support in the medical record. Place of service. Place of service designation also has not changed. The place of service is defined by the location where a face-to-face encounter took place with the patient or a caregiver. We still have observation, inpatient, outpatient, office, all of the designations of places of service. One thing we've been asked, the admitting provider is also identifying by the AI modifier. That has not changed. So if you are the admitting provider, you do report your service with the AI modifier and that is not something that has changed. Definitions of new patients. It does vary by site of service, payer reimbursement. When you look at the definition of new patients, the only thing that was updated for this year was under that middle box, the initial service which covers our facility, inpatient, etc. New patients are defined as the care rendered to a patient who has not received any professional services by a physician or same specialty or NPP group member during the current stay. So when you think about a new patient in a hospital facility setting, an initial service is based on that current stay or current episode. When we look at our office and outpatient setting, that has not changed. It still remains that three-year period if they've not received any professional service by a physician or same specialty group member during that three years. It's important to remember that our nurse practitioners and PAs working with physicians are considered working within their exact same specialty and subspecialty as that physician. As we know, our PAs, nurse practitioners, have their own designated specialties and they are not subspecialized or dedicated to cardiovascular EP or any particular specialty. It does fall under the physician they are working with. So let's start with a little bit of the information from our Medicare carrier. So this is NGS, National Government Services, and this was one particular for cardiology. So in a cardiology group, we have several specialty types, cardiology, EP, interventional, etc. If a patient has been seen as a new patient by one member of the group, how is a visit with another member of the group billed when the specialty type differs? As in all multi-specialty groups, when patients are seen for the first time by a group member of a different specialty, each specialist may bill a first encounter with the patient as a new visit. When group providers of the same specialty see a patient, that's considered an established patient. I think it's very important when I said that new patient definition is truly dependent on what site of service you're in, what is the payer, is it Medicare, Medicare Advantage, is it a commercial payer, if they really recognize specialties and subspecialties. We often get questions about, well, we do bill our EP physicians as a new patient. We get denials on those. And when I did this research, it was interesting. Many of the Medicare carriers talk about that. And they talk about that it may require an appeal. I wish that we could get this resolved in systems when we are billing this, but this is just an example from NGS. As with all this information, you should check with your specific carrier. From Novitas, this is one that they talk about that they're seeing denials for physicians' new patient visits indicating the patient was seen by our group in the last three years. Why is this occurring, and what can we do about that? So this is related to our office place of service, outpatient place of service. So again, they talk about the same thing on the previous slide, that physicians are trained in different specialties. One thing, however, that I thought was important that they called out here, they go over the definition of a new patient based on that place of service, outpatient or office, says currently under the CMS enrollment process, NPPs cannot designate a subspecialty. So it goes back to reminding us that if they saw an NPP and working with the physician, and they may be considered that they weren't a new patient, depending on if they saw that NPP working in the same specialty. So they may be something you want to look at in your denials if you have NPPs seeing new patients. A lot of groups do not have nurse practitioners and PAC new patients and bill under the new patient. But if you have that, you may want to look at some of those denials. And then this next one, am I permitted to bill an initial hospital visit or consultation even though I have an established relationship with the patient? Remember, nothing's changed with consultations. Medicare does not recognize or pay for consult codes. And it says here, yes, the concept of new or established patient does not apply to the inpatient hospital care days. Practitioners can use these codes for the first visit to an inpatient, even if they have an established relationship with the patient. So that's just around that initial stay. Another clarification to remember, per AMA in some of the guidelines, particularly when they were talking around admissions to the hospital and the observation status and the merging of these codes and even around hospital emergency departments, they talked about that a modifier 25 may be added to an E&M service by the same physician performed on the same date. This has caused some confusion from the AMA guidelines. However, CMS has been very clear in the final rule, and many of the Medicare carriers have been as well, that they retain the policy that you can only bill one E&M per service provider per calendar date based on their specialty. So that's important to remember that it's one E&M by specialty per day. Can two different providers bill a rounding visit on the same day? This is Novitas. Subsequent hospital care codes are per E&M services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. Physicians of different specialties may each report a subsequent hospital visit on that same day. So this is one of their new FAQs that they've updated out there, and it does talk about the different specialties. One thing to remember is, even though the FAQ supports this, the documentation of those providers needs to support the medical necessity of the visit and the particular reason that they're seeing that patient for that service on that day. So if you have providers from different specialties seeing the patient for the same issue, that could present a problem in your documentation, and you want to be sure that your providers are truly documenting based on what they are seeing that patient for for that particular day of the encounter. Couple of things around some of the deletions and some of the crosswalks. So our discharge observation discharge code, the 99217, our initial observation codes, and our subsequent observation codes have been crosswalked to what are now the inpatient observation services. So discharge, we have available our less than 30 minutes, which is the 99238, and over 30 minutes, which is the 99239. If you're reporting inpatient for observation, it directs you to our H&P admission codes and our subsequent rounding visit codes. If you're reporting outpatient, meaning that you're seeing the patient and they are in an outpatient status, and you are not the admitting observation provider, then it tells you from a CMS standpoint that you should use the outpatient office service, new patient, and established visit codes. So this is one thing that differs, and there was from the AMA guidelines, and there's still a lot of back and forth on this one, and it's not very clear across payers. And I did get a lot of emails around this since the beginning of the year saying, my payers are denying my initial codes for observation services. We're getting denials on this, we're getting denials on that. And what we found was that many of the Medicare carriers hadn't updated their websites, and you'll see a couple examples I have of them posting that as well. From first co-service options, this was updated for 23, and they even referenced the AMA CPT guidelines on this one. They talk about what are the guidelines for determining the use of observation versus office visit codes in the outpatient setting. These are provided for your reference. I'm going to focus on this last paragraph. Payment for an initial observation care code is for all the care rendered by the ordering physician on the date of the patient's observation service began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. So this aligns with what National CMS put out in the final rule. If that patient is in outpatient observation status, you're the consulting physician, and you see that patient, then you would bill the new patient office outpatient services or the established visit office outpatient service codes. From Novitas, they do have a fact sheet out there for observation services if this is something that you get exposed to in your programs a lot. What I've seen in observation services is you have to remember, and the fact sheet really drills down on that, if you are not the admitting physician to observation care, then you are not the provider who bills observation care codes. And this one, again, on Novitas says that all other practitioners providing care would bill the office and other outpatient service codes. So again, they're starting to update the content there. This is one on WPS, and I saw someone posted that some of the other carriers are starting to post some bulletins. One of our members shared this with us graciously as we were putting together this content about they've even posted this saying that there were erroneous rejections for observation services, and they are going to perform a mass adjustment for the affected claims, and they give you the codes. So if you're having issues with your place of service and the codes that you're billing for initial rounding or discharge services with places of service 19, 22, or other places of service, you may want to check your carrier website as they are beginning to say, hey, we didn't update our systems for January 1 to be able to accept these codes with that place of service code. We found that error, and now we're going to do a mass adjustment. So definitely some nightmares on the denials coming in and what you're seeing, because the systems aren't updated timely. All right. Same date admission and discharge services. These are the 99234 to 99236 codes. These apply to services when an admission and discharge to either observation or inpatient status have been completed on the same day. This is performed and billed only by the attending or admitting observation inpatient physician who is discharging and admitting that patient on the same date of care. You do have to take in consideration the observation rules which remain in place for CMS. Billing stays of eight hours or more is what these codes pertain to, and they talk about if it's a stay of less than eight hours, it points you to the hospital observation inpatient codes. And this does require documentation of two encounters, one of the admission and one of the discharge. I don't see these too often in cardiovascular services, as normally we're not the attending physician or admitting physician to observation. I think that's one thing to remember as you go in, and also these services are not billable if the patient's having an elective procedure that same day or a procedure service that has a global period, so you have to make sure if you're billing for these services that you're billing these correctly. For the discharge service codes, this is a clarification to the guidelines that were issued this year. It's the time reported on the date of the encounter that can be counted towards the 30 minutes or less or 30 minutes or more on the date of the encounter. So that is something that was added for 23. It's used only by the physician or qualified health professional, which is our APPs who are responsible for the discharge. So that would be the admitting or attending physician who admitted them that would build the discharge service. Services by other providers, including instructions, coordination of care, et cetera, are reported with our rounding subsequent codes if that patient is an inpatient and being discharged and your provider sees them and they're the consulting provider, they're going home that day, they would fill the rounding visit codes if they're not that admitting attending provider. And then this also points to if they meet that criteria around the admission and discharge the same day, the information we just discussed. For consults, the AMA retains consult codes and there's some minor revisions there. There's no changes from a Medicare CMS standpoint. They do not reimburse for consults. I'll tell you across the country, we probably see less than 15 to 10% of insurance carriers reimburse consult codes in our cardiovascular services. Most of that is, you know, a lot of our Medicare Advantage plans follow these guidelines. Many of the big commercial payers have begun following these guidelines as well, but there are still some payers who follow that they will reimburse consults. And that's gonna be particular to your region. And we wouldn't even be able to tell you who those are and where they are because it is so state-specific, region-specific. And based on your particular carriers. For emergency department services, these are used to report services provided in the emergency room department only. That's not new. They maintain the existing principle that time cannot be used to determine the level of selection for an ER visit code or needy visit code. It's based on medical decision-making only. It's still the same existing codes. And just remember, when we talk about time-based service codes, such as emergency room and critical care services, those have to have the exact time documented, whether it's total time or clock time. Avoid use of less than, greater than. Use total time is much easier. And you can report E&M visits, ER visits, and critical care service with critical care services on the same day. So you may see a patient in the morning on a rounding visit, for example, and then they require critical care services later in the day. You are able to bill for both of those services. Same things with ER visits and critical care services. The key is no overlapping time can be counted based on which service you're providing at that time on the date of the encounter. For history and exam, we already mentioned that now the HPI review of system, past family social history and exam defaults to what is medically appropriate and pertinent based on that clinician and to the nature and extent of what they feel and is documented based on that patient's condition and care for that treatment that day. One important thing to remember and that they do call out is that the chief complaint or what we consider the reason for visit is required on E&M services and it often supports medical necessity. So having that information of why am I seeing the patient today for this particular encounter often supports the medical necessity of that visit. It's interesting, I've gotten a lot of questions about, well, do I even need to do an exam now if I'm seeing a patient or do I even need to do any type of history element? So on clarification on NGS, they've eliminated specifications for the scope of exam and associated documentation in the office and outpatient settings and the hospital settings, but the provider is expected to perform and document a pneumatically necessary and relevant exam based on that patient's presenting complaint and or known history and on the examiner's observation of that patient's condition. I do not think it's a great to just totally omit an exam on patients because I do believe this supports, you need that clinical relevance to support the medical necessity of that visit and most of the patients that you're seeing as a specialist, they require an exam. Now, there may be some patients you're seeing and particularly if you're billing based on time and it's a lot of discussion, counseling, those types of things that you may not examine the patient, totally understandable but I believe largely you won't see that an exam will totally go away or shouldn't totally go away from a medically necessary standpoint to support that it's meeting that patient's presenting complaint, known history and the observation of the service. For providers selecting the E&M service, so since we don't have to count those HPI review assistance exam elements, what is it based on? What's based on that level of medical decision-making or the total time of the service performed on the date of that encounter? So we're gonna talk a little bit about both of these. So in order to meet medical decision-making, you have to qualify for two out of three of the medical decision-making elements. 95 and 97 guidelines totally go away. Also, I've heard reference to 21 guidelines. When you review the CPT guidelines in the E&M category, everything's been renamed to 23 guidelines. Yes, in 21 outpatient and office services changed. In 23, inpatients and other services changed. But now what we have is the 23 guidelines by AMA and accepted by Medicare, except for a few things that Medicare didn't align with that we've talked about. So what are the three elements? The first one is number and complexity of problems addressed. The second is complexity in an amount of data ordered, reviewed or analyzed. And the last one is that risk category. So you have to meet two out of three of those categories to determine your level of risk based on the medical decision-making table. So this medical decision-making table supports all of our E&M categories that are based on medical decision-making or time. So office, outpatient, inpatient, observation, those that are, when you look in the CPT book, this is the table that you're gonna see and this is the table we should be using. There were just a couple of tweaks for 23 to add to the medical decision-making table, a few items to support our hospital observation services. An example would be under moderate, they added one acute illness with systemic symptoms or one acute complicated injury to support our facility services. And they edited a couple of other items based on risk and the number and complexity of problems. But ultimately this has remained the same as the 21 table that was published when our office and outpatient services came out. I'm gonna talk about a couple of key examples from the medical decision-making table. I think one of the things to remember is when you're counting the amount and complexity of data, it's important based on your level of medical decision-making that you're meeting the categories that they specify depending on your level of service. So if you're meeting data and another element of the medical decision-making under moderate, so say you're meeting it on two or more stable chronic illnesses on moderate and then you're meeting data, when you look at data it says you must meet the requirements of at least one of the categories and there are three categories. So you have to follow those specific instructions to meet one of those particular categories. When you get to your high levels of service that goes to two out of three categories. Oftentimes we're asked, well, if I have a patient that's on a high risk medication does that automatically make them a high? What I will tell you is that can't be the answer, can't be yes, because you have to meet two out of three of the components. So if you meet it on that you've documented that they're on a drug therapy requiring intensive monitoring for toxicity or they're at high risk, are they meeting either the number and complexity or problems or the data category on the date of that encounter? So it's not just based on this one particular patient that may be on a high risk drug. They would have to have one or more chronic illnesses with a severe exacerbation progression or side effect of treatment or one acute or chronic illness poses a threat to life or bodily function in order to meet number and complexity of problems and risk. Or if they meet risk, they would have to meet the data category which you have to meet two of these. So that would be that you have tests, documents and independent historian if you review external notes, results, ordering, assessment, any combination of the three to meet category one, then you have to meet category two or category three in order to meet it on data. So I think it's important that when you're, if you educating your providers or providing information to providers or coding these visits that it's not just about that risk category, it's I have to meet one of those other categories. And that's just one example. And we'll talk about some of the clarifications around that. All right. So medical decision-making, I'm gonna break down a couple of things around each of the elements or categories of the three. So on problems addressed, only listing conditions comorbidities are not considered in selecting your level of E&M service. This would be an example of that. You pull the problem list only into your note and you have eight problems listed and you only address or document the complexity or treatment of those conditions. You only document maybe two. Those two conditions are the only conditions that can be counted towards the medical decision-making in order to meet the table on risk, number of problems or treatment. It's important that we talk about what does this mean for risk adjustment? Risk adjustment is around our diagnosis codes. So when we talk about diagnosis coding and that risk adjustment and are we capturing all of those categories, it's not just about capturing the diagnosis, capturing the problem list. It's also about, did you address the condition? Did you document the complexity, your treatment to support that medical decision-making? There are also some clarifications around the final diagnosis in and of itself doesn't determine the complexity of risk as extensive evaluation may be required. So this would get into extensive treatment, those types of things. The evaluation and treatment should be consistent with the nature of the condition. And we have to remember that medical decision-making table is only a guide in selecting the level of medical decision-making. All right. So NGS, when reviewing documentation to the diagnosis, always be listed in the assessment or plan or will they allow it to be extracted from the note? I probably get asked this question not just with the new guidelines, but always. We have to remember that that documentation for the day of the encounter is the documentation in its totality. So it's not just that it should be in the assessment and plan. It can be anywhere in the documentation. But what I will tell you, and they clarified here, that best practice is probably that you should list it in the assessment and plan, especially since the number and complexity of diagnosis will be factored into the level of complexity for the visit. It does go on to say that that cheap complaint may include a reference to the diagnosis or maybe phrase in the patient's own words as the reason for the visit, but the diagnosis billed on the claim is expected to be clearly stated in the provider's assessment and plan. Now, many carriers vary on this. I'm a big proponent about review the note in its entirety. Yes, does it help if it's listed in the assessment and plan and it's clear and documented? Absolutely. But, you know, we get a lot of information in different formats of our notes since our EMRs pull over and copy and paste different sections of our note. So be sure you're looking at the clarity of that documentation. So amount and complexity of data to be reviewed and analyzed, couple of call-outs. For category one, each unique test or order defined by CPT counts as one point. However, tests included in a panel count only as one test. This comes up, so if I order a CHEM-12, I'm not going to count BUN creatinine potassium as three distinct tests. If I order a CBC, a CHEM-12, and a lipid panel, that's three unique tests, as an example. If a lab is ordered, it's implied that the lab will be reviewed. Make sure not to count both the order and review of the lab separately. Diagnostic tests considered but not ordered count towards the E&M level in 23. This is something that's in the guidelines. Be sure that all tests considered but not ordered, as well as the shared decision-making that took place, are documented. So if there's some shared decision-making and there's discussion about that patient on tests that may be explored, ordered, they're explained, those types of things, are you getting that documentation for that to support the data reviewed? Independent interpretation, of course, if you are billing for an interpretation of the test, you cannot count that towards independent interpretation. We did get a lot of questions around, can independent interpretation include telemetry monitoring strips? So if you have a patient being monitored on telemetry, can that be considered as independent interpretation? I found several references that state, just as we can't report telemetry separate, telemetry does not have a CPT code and it does not have an interpretation or report that is customary. So this is not considered an independent interpretation. When we're not allowed to bill telemetry with an E&M service, if it's just review of a telemetry strip, it's included as part of that E&M. Again, not a separate interpretation and a separate report is not customary. For external physician or other QHP that they refer to, qualified health professional is an individual who is not in the same group practice or is in a different specialty or subspecialty. So that's one thing to remember about your external physician discussions. And then appropriate source definition does not include family or informal caregivers. And these are the examples they give, lawyers, case managers, police, et cetera. So I encourage you, we have the reference or resource to the AMA complete definitions that gives you all the context, but reading those definitions can help with explaining what each of these categories mean and how to count that towards your medical decision-making. So let's talk about risk. So for risk, the AMA published this FAQ that is definitely something I think needed to be clarified around prescription drug management. So prescription drug management is in our moderate risk section of our medical decision-making table. There's no blanket guidance for the specific level of risk, but it does talk about that the physician cannot just simply review a medication list to constitute prescription drug management. So this has come up in your EMR. If you have a little check box that they can check at the top, and it says medication list reviewed, and that's the only documentation you have, then that can't be considered prescription drug management. What are some examples that can be considered prescription drug management? If you have a patient, for instance, who has hypertension and the physician documents that they're going to continue their biostolic, that's prescription drug management. If you have a patient who has hyperlipidemia and you're going to refill their Lipitor and they're going to continue to take that Lipitor, that's prescription drug management. A new prescription, a new medication started, obviously that's a new prescription. So it's all in that documentation. One thing I often say is if you list all the problems and then in the bottom of the assessment and plan it says continue medication, what do you count that towards? Which problem being addressed? If there's no other information, you can only count that once unless there's specifics related to the problems or conditions that were pulled over. So I try to encourage folks, you want to be sure for prescription drug management, for meeting the documentation, severity, complexity, treatment of conditions, that there's some clarity there. It doesn't have to be a lot of words, but using those blanket statements and how your notes look to someone who's reviewing that from the outside is important. For minor or major elective surgery, there's no change in the definition of this. They did clarify, and that's been clarified since they put this out in 21, that minor or major surgery is not determined by the surgical package, meaning the global package. It's determined by the risk factors that are relevant to that patient for that particular procedure. And that's determined by the clinician. Elective and emergent, the definition's pretty clear there. Elective is if it's planned or staged, and then emergent is considered that it's performed immediately or without delay. And that patient, no delay because of that patient's stabilization. So when you're looking at moderate versus high, how are you documenting? What does that look like from a risk factor perspective relevant to that particular patient's conditions and that procedure? So the clinician determines that, but the key here is on the date of that encounter that you're seeing the patient, what is the relevant risk to that particular patient based on that procedure? Drug therapy requiring intensive monitoring for toxicity. So there's some clarification, and I think the biggest call-outs here is that these are drugs requiring intensive monitoring. They can be therapeutic agents. The monitoring cannot just be by history or examination. That does not qualify. Generally, you'll see monitoring performed by a lab test, physiological test, or imaging. The monitoring affects the level of medical decision-making in an encounter in which it is considered in the management of that patient. Again, remember our clarity on the date of the encounter. So if that patient is on a drug requiring intensive monitoring, just listing the drug doesn't tell us how that drug is being monitored and how is it being considered in the management of that patient and the concerns over the monitoring effects. So it's not just about listing that drug. Again, drug therapy requiring intensive monitoring is under our risk category. When you look at our categories of number and problems addressed, data, and risk, they have to meet two out of three of those categories to determine your risk. So just if they're on drug therapy requiring intensive monitoring, they may meet high risk if that's documented and supported. However, you have to support it with one other medical decision-making component, either in their number and complexity or problems or the data for that visit on that day. This is an example, and we often see a lot of these lists. The key here is that several entities, several Medicare carriers, some Medicare carriers, some insurances have posted what are considered drugs requiring intensive therapy. This is not an all-inclusive list, and it can be determined by the clinician based on that treatment of the patient and the monitoring and the risk of that overall patient. So just remember that when you see these lists, they're not all inclusive. All right, a couple of E&M scenarios before we jump into split share in time. All right, so this is our moderate medical decision-making table, just a refresher. We talked about, you have to meet one of, oops, sorry, one of the, two of these three, the number and complexity of problems, amount of data or risk in two of these categories for moderate. So on this particular patient, and we're gonna say, when you look at these examples, these are scenarios only. We're gonna say this patient had a beautiful exam documented and it was an extensive note, but for the webinar, we're pulling out just those key areas to look at from this particular note to illustrate what a rounding visit level two or subsequent visit level two may look like. So this particular patient, we have a little subjective information. I mentioned they did have an exam and then the physician talks about that they have intermittent third degree AV block. It's being managed by another physician who's gonna bring them to the lab for a pacemaker. This physician seeing them for severe aortic stenosis, their status post TAVR, they're ecostable and they're on Plavix for three months and an aspirin. Their acute kidney injury is improving, their hypertension's controlled and their hyperlipidemia, they're on a statin. So to simplify this particular example, to meet moderate medical decision-making, I have two or more stable illnesses and then I have prescription drug management and that meets moderate. So I don't even need to count my data if I know I've met it on number and condition of problems and risk. So sometimes we get wrapped up as coders into counting that data. You wanna be sure, am I meeting it? When I look at these notes, am I meeting it in the number and complexity of problems or risk? And then I go to data. It's probably a matter of preference, but I know it's just a lot easier when you're looking at these to make it as simple as possible. So for our high medical decision-making, again, this is our table for that. This particular H and P, and I think it's important, I'm gonna have a couple of call-outs on this one. This is a patient that was a consult for acute on chronic diastolic LV dysfunction. In the HPI, they talk about that they have known CAD, status post-CABG, and they go over testing. So they do that of their CABG, they do that of their TTE, their left heart cath. And this last sentence says, the patient presents with progressive shortness of breath, dyspnea on exertion and edema. She's being admitted for decompensated heart failure and hypertension. Then I get to my assessment and plan. Again, we're gonna say they had a comprehensive history, comprehensive exam. The data, the EKG labs and checks x-ray are pulled into the note, and they're from previous dates. There's nothing that says they were independently reviewed if they were ordered or read or interpreted by this particular physician, they're just pulled into the note. But then he talks about acute on chronic heart failure, secondary to their hypertensive disease. And he talks about diuresing and titrating for blood pressure control. Goes over five of their other conditions here. And when I look at a note like this, and this is common in our world, that we see that the sections of the note are pulled over from previous visits. And how do we know, did they order anything new? Did they, you know, is this something that they didn't order, but they're independently looking at? So what I would say was, would you count that previous data reviewed? Well, it depends, you know, did they see one of my docs before? Is this patient familiar to him? What information did I have? What about the data that's just pulled into the note? Same thing. Is the risk illustrated for this patient? Are the problems addressed? And are you looking at the complete note? So here, when they talk about acute on chronic, secondary to hypertensive heart disease, he talks about diuresis and blood pressure control. It's going to order an echo. And he talks about continuing his home meds and titrating for blood pressure control. Here, he said that he's having progressive shortness of breath and dyspnea on exertion, and he's being admitted for decompensated heart failure. So it didn't give me all of that here. However, if I look at this note in totality, I look at where we're at, and could this patient be on that higher risk category to bill at a higher risk? So this one probably with, I think we have 542 people logged into the webcast today. We probably could spend time on this and say, wow, I'd code this a high level. And then I'd probably have a half of you say, no, I think this is moderate. This just is about what is in the documentation and the interpretation of that documentation based on what you have documented. And I'm not sure how you count data knowing that this is a 33-year-old woman known to me with coronary artery disease. So I'm talking about her previous studies. Chances are more than likely. Am I reading the report or looking at images? Doesn't really say that. It does say that she is, of course, acutely ill, decompensated, having progression. So yes, meets it there. But when I look at the other two high risk categories, is something going, they're diuresing them, but they didn't tell me that they're on a drug-retiring intensive monitoring and they're gonna monitor it with lab work or anything. Didn't tell me that. So even though I may reach it on high risk, I'm not necessarily gonna meet high on my data or my risk here. And this would be a moderate patient if I don't have all the details of the note. Could it be a high patient? Yes. If I had more information and had more details in the note. That's why that documentation is important to stand alone and really support that level of service. So again, we could all have differing opinions on that one. This is a scenario that supports a level three rounding visit. This one's pretty straightforward. I highlighted a couple of things here because I think these are great documentation points for your physicians. One is you can see that he clearly documents, this is a worsening patient. And then he talks about, he's gonna repeat the troponin, the EKG and get a limited echo. And then he says the case was discussed with the ICU physician and the interventional cardiologist. So he's getting that second point within that data that he's discussing the case outside of his group with. Now, Dr. S, the interventionalist may be part of this group but the ICU physician isn't. Can we get that clearer? But again, just ways to look at documenting other elements of data and the worsening of those conditions. Right. Briefly on time. So when we look at time, the call-outs that are important, 95, 97 goes away. It's included the total time on the day of the visit and the time is only the physician or the APP time. And it can be preparing to see the patient, obtaining and reviewing history, doing an exam, counseling, ordering medications, communicating with other healthcare professionals and documentation of the clinical information. What's not counted? Travel, teaching that is general and not limited to the management of the specific patient that you're seeing on that date of the encounter. The performance of other services. So if you're interpreting an echo, for example, you can't count the time that it took you to interpret that echo. If you're billing transitional care time or chronic care time, no overlapping time. If you're seeing the patient at the same time as the physician and the APP together, they both can't count their time if they're together at the same exact time, only one can. And then activities performed by clinical staff cannot be counted as well. This is an example of just the time elements on time thresholds. The call-out here is that for office and outpatient services, it's the date of the encounter and you have a time range. When we talk about our hospital services, observation inpatient, you have that they have to meet the time threshold of 40 minutes and greater as an example. So you have to meet the 40 minutes or exceed it, meet the 55 minutes or exceeded. And then on our discharge services, important to remember less than 30 minutes or more than 30 minutes. How is that documented and illustrated? And if they document more than 30 minutes of the time, are they giving me clock time? Am I able to say it did meet 35 minutes of the time? Discharges I think are gonna get a little tricky on time because they clearly say they're time-based services. So I'm a big proponent for best practice that we are keeping this patient you know, 35 minutes to do their discharge or we're doing 25 minutes. What is that exact time? And when we look at the RVUs this year and what's happened to the RVUs on our hospital services, they decrease the initial and admission codes a bit and increase the rounding visits and the discharge services. So I thought that was interesting as well from a work RVU perspective. All right. Does the provider need to be on the patient unit or floor when performing non-face-to-face services that contribute to time? So this is for 23 and our facility or other E&M services. And it says when time is used in reporting the E&M service, it's defined for selecting the level. The guidelines apply to face-to-face with the physician or qualified health professional, which is our APP. But it says for coding purposes, time for these services is the total time on the date of the encounter. This does include both face-to-face time with the patient and our family and non-face-to-face time personally spent by the physician or APP. So it's important that you're counting only time on that date of the encounter for that particular patient, whether it's face-to-face or non-face-to-face service. It includes time regardless of the location or the APP. So whether they're on an inpatient unit or where they are, but it does not include any time spent on separately reported services, other patients. Time is tricky. Don't see time build a lot, but I do see it in some subspecialties where it makes sense. When you look at those time thresholds though, pretty difficult to reach some of those in our hospital services, unless you have a patient that you may be taking care of multiple times a day, talking to family, coordinating care. Generally, we see more critical care build on those types of services, but time could be an option based on your patient base and your specialty. Prolonged services. They deleted the prolonged services codes 5-4 to 5-7. They revised the guidelines for 9-9-4-1-7 and 9-9-4-1-8, which is prolonged services on the date of an E&M services for inpatient and outpatient services. These are the ones Medicare does not recognize and they created their own G code for. They also revised the guidelines. We had places and programs that were using the 9-9-3-5-8 and 5-9, which were prolonged services on a date other than the face-to-face E&M without direct patient contact. CMS this year has designated these codes as invalid for 23. So that's something that they did no longer available from a CMS reimbursement perspective. They also revised some guidelines around the 1-5 and 1-6. So briefly on prolonged services, the 9-9-4-1-5 and 1-6 represent clinical staff time during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision. So this one, you need to read all the guidelines if you're considering it. It's only added after a face-to-face service by a physician or an APP. So it can only be built after that face-to-face visit. It requires a full 30 minutes of additional time after a 9-9-2-0-5 or 1-5 by the physician or the APP. And it can't be used if the patient's awaiting test results or somewhere in the office suite waiting. I thought it was interesting they called that out in the guidelines, but again, only used on level five office outpatient services. They have to have a face-to-face with a provider and it requires a full 30 minutes. For the 1-7 and 1-8, the 1-7 is the outpatient office services. The 1-8 is the inpatient observation. And again, these can only be added to our high levels of services in both of those locations. And these are not covered by CMS. CMS has their own G codes to represent those codes. And you will see when you look at these G codes for the hospital, as an example, the time threshold to report on a high level admission is 105 minutes on that date of visit. And there's a consistent approach about what represents a fully completed 15 minute segment. So if you're entertaining billing, prolonged care, be sure to look at all of the guidelines that are out there. And again, there are on our higher levels of service. I don't think we'll see these reported too much in our world. Maybe I'm wrong. I'd love for you to share a situation where that come up. All right. So we are gonna finish up with split shared services and we'll have 15 minutes for questions at the end. So for Medicare, the options for billing for NPP, which is our APP services, CMS still uses NPP in our world. Most of us use APP or APC. There's three options. The NPP can bill independently, see the patient, complete the note, bill under their provider number, their credential, and they're reimbursed at 85%. Incident two applies to place of service office 11 only. And you do have to meet certain criteria to support incident two. It's a patient who has a established plan of care, no new patients or problems, and they don't have a change in their plan of care. A physician has to provide direct supervision within the office suite. And if all of those requirements are met, the APP is employed by the physician or group, or there's an agreement with the physician or group, it can be billed under the physician, meeting the requirements and reimbursed at 100%. It's billed under the physician, reimbursed at 100% with requirements met. For under the APP, it's 85%. For split shared services, this represents services that are performed in the outpatient or inpatient hospital services. So if you bill as a hospital outpatient department in your clinic, 19 or 22, this could apply to your clinics, also to all of our inpatient service levels. This year, they did extend the same guidelines as they implemented in 22, that split shared services is determined by who documents the substantial portion and meets that definition, or more than half the time, total time determined. That's how the billing provider criteria is met. It's billed with an FS modifier, reimbursed at 100% by the physician. If he performs, he or she performs the substantial portion or half the total time, reimbursed at 100%. Or if it's the APP, billed under the APP, it's reimbursed at 85%. So what are some of the particulars? There are payer differences. Private payers may have guidelines or specific policies. Many defer to the state law or scope of practice. Most private payers don't credential your APPs and they request that you bill it under your supervising physician. Medicaid has different rules than Medicare as well. We've seen that be state-specific also, and they may require it to be billed under the physician who's providing direct supervision. So based on your state, region, and payer, you wanna be sure that you're meeting the requirements for your APPs and your physicians. Incident two, office-based services. We talked about that this is applied only in the office in a non-facility setting, so not our hospital outpatients. The patients are established. They have an established plan of care. It's not relevant for new patients. Direct supervision is within the suite, so it has to be billed under the physician who's meeting the definition of direct supervision, and the APP has to qualify as an employee. For split share, for the substantive portion, this is unchanged from last year. The billing provider must perform one component in its entirety, and that provider's documentation must support the component that chooses the level of service. So I can take the entire note into consideration, but whoever's documenting the substantive portion has to support the level of service chosen. Components, history exam, or medical decision-making. For split shared services, remember now, we are now choosing our levels of service based on medical decision-making or time. However, for split shared, you can still use components, history exam, or medical decision-making to support the substantive portion of split share. I think it's a lot easier if you use medical decision-making. Of course, that would be Nicole's wish, but it does not mean that that's the only thing they can document in its entirety to support billing it under a provider and appending the FS modifier. For time, it's important. They were going to implement time only in 23. They clearly say that they're gonna revisit this next year, and it could be implemented. I'm not sure if we'll see that. The goal this year, though, is that you still are able to meet split shared based on who does the substantive portion documentation or who meets greater than half the total time. We talked about what qualifies for time, not much different here, but being sure that you meet those requirements if you're billing based on time. All right. So a couple of things on split shared. For NGS, would you consider a split shared visit if the physician's documentation was listed as an addendum on the NPP's note? Split shared services in a hospital setting require performance of necessary elements or cumulative time spent by both the billing physician and NPP. The only way for a physician and NPP to describe his or her own personal contribution to the service is to document an individual note describing the portion of their service performed. Now, granted, that note, I would say we primarily see that as an addendum. I don't think they're saying it can't be an addendum. I think what they're saying is the physician must clearly document their note and the APP's note and what they did must be clearly documented. Example, I've seen and examined the patient with the PA and agree with the assessment and plan and physical exam findings. And then a summary of items and data already listed by the PA. The physician is indicating his or her participation in the final physical exam and review of medical decision-making. This would be adequate to support the medical decision-making. Well, when you look at this example, so this is what we normally see in our attestation. It says at the bottom, in order to bill the services, a substantial, the provider must document the substantial portion to describe the physician's work as exceeding the NPP's work in completing the service. In either reviewing the NPP's history or exam findings and furnishing medical, formulating medical decision-making, the physician's performance and documentation would need to exceed the NPP efforts and documentation of the split shared service. So what is this telling us? Basically just having an addendum that says you participated in the care and that you reviewed and those types of things. We know that doesn't support split shared anymore. You can have that in there, but you also must have, if you're billing based on substantial portion, you must have what portion of the note did the physician document to support that in order to bill. And it can't just be that they agree with the above. How will the substantial portion visit be defined in 23? It relates here. It talks about just what I did, that you can still do it by completing any of the following elements. You just want to be sure that that documentation is clear on who performed what element. Palmetto for purposes of payment, the following conditions apply. I wanted to call this out because we're often asked, do both providers have to sign the medical record? Sometimes this isn't about billing. Sometimes this is about hospital guidelines, and it may require that the physician sign and document on the APP's note. It may not have anything to do with billing, but it may be required. Here it tells you documentation in the medical record must identify the physician and non-physician practitioner who performed the visit. The individual who performed the substantial portion and therefore bills must sign and date the medical record. So here it's specifically saying if they did the substantial portion, they must sign and date that medical record. So all those details are important, but remember if your providers are required to sign notes after their APPs, it might not always be related to billing. It could be related to if it's a requirement of their medical stat privileges, et cetera. Nearing the end here. So this is documentation, and it's included in your handout. I'm not going to read through this note in its entirety, but this is a beautiful note by an APP, which we often see, and they've described all the components of the note and documented and signed their note here. Then we get to the provider or the physician's note. So he talks about that he personally saw and examined the patient and goes through all of that stuff. He personally formulated the plan of care, and he reviewed the pertinent lab data and reviewed the EKG, and then he did an addendum, and he talks about the patient is present with acute on chronic heart failure, do not taking his medications. He refused a pacemaker. He talks about his quality of life and that hospice is recommended. He performed 100% of the medical decision-making, the patient's at high risk. He personally reviewed imaging, blood work, dah, dah, dah, dah, and then he says, I personally performed the exam in history. Obviously, there's a lot of personally performed in this addendum, but it makes it pretty clear. I would not go back and say to this provider, how do I know you did it in 100%? Obviously, his medical decision-making, if it's based on medical decision-making, has to support the level of service being billed, but this would support split shared services and be billed with the FS modifier. We are seeing a lot of physicians document, I performed the medical decision-making in its entirety, or I performed the substantial portion of the visit in its entirety, and then documenting what that is. I don't think there's anything wrong with that as long as you document all the elements that are needed to meet, if you're doing medical decision-making, two out of three components of that medical decision-making. This is another one around a rounding visit and what we see, and again, personally performed the medical decision-making in its entirety, and then he talks about the medical decision-making. They do clearly say that even though he says that he performed the medical decision-making in its entirety, it doesn't mean the APP can't document any of the medical decision-making. There's nothing that says that. There's actually some FAQs out there that say, doesn't say the APP cannot document anything on the medical decision-making, but what it does say is, I have to clearly know who's performing the substantial portion in its entirety, and if the physician's telling you that they did, and they're giving you the elements, then it's the physician who's performing that. So, always opportunities in split shared, and it's never straightforward. Again, I encourage you, review those notes with your providers and have some conversation around what can improve those notes. I do believe we'll see some audits on that this year, nothing to be afraid of or not a scare tactic, but the FS modifier is being applied for a reason, and I do believe that's going to be some of the audits that we see coming up. Just as an update, this came out this week that the Biden administration is ending the public health emergency on May 11th. This is going to impact several policies and waivers. Not going to go into detail about that. There is still not updates on many of the Medicare websites, like some of the telehealth lists haven't been updated since November of 22, and don't even incorporate some of the final rule where some things have been extended to 2024. I would just pay close attention to this, and we'll continue to share as much information as we have. There's a link here that takes you to that information, but again, ending the public health emergency, and we know that when we looked at the final rule and went over that webcast, there was a lot of information around. It's extended 151 days for some services. It's extended to the end of the year, so there's several moving parts here, and again, another thing to watch for updates. All right, so some key takeaways before we take a few questions. Connect with providers on definitions, wording, and clinical terms to improve communication and documentation. Try not to focus on exceptions. Is it a pattern? Does it happen less than five times? That's one thing, you know, when I hear, well, this happens, and it's like one scenario that happens once a year. Don't focus on those. Focus on the things that happen, and it's a pattern, and how can you impact that pattern? Simplify the messaging as much as possible and make it a win for everyone, so little bits often and repetitive is what we've seen work. So now we're going to open it up for some questions, so I'm going to take a look at my question box here. I know that some of my fabulous team that's on the line has been answering some of those questions, so if a patient is not a new patient to the provider, can they still bill a new patient code if seen in hospital observation status? Well, that depends, so if the physician is seeing the patient in consult and the patient remains in observation status, then it points us to billing them under our new patient codes or our established visit codes. If it's a physician who has seen that patient within three years, then you would be billing that as an established code, so that doesn't change that. It's going to depend on what code category you're using. Now, when we talked about what's impacted on the physician's stay, that was around our inpatient service stays and if you were billing observation care codes. So again, it's confusing, but if you use office and outpatient services, those codes have the three-year rule. All right. Can 99285 be billed by different providers on the same day? So this is our emergency room service codes. Emergency room codes are only billed by providers who see the patient in the emergency room. If you're the consulting provider and you're seeing that patient in the emergency room, depending on if that patient's going to be an inpatient observation or remain an outpatient and go home, you would have to bill the correct code category. So I do think that more than one provider, it has been said, can bill an emergency room visit on the same day, but what I would say is you need to be sure you're in the right category based on your provider's specialty, the place of service of the patient, and what is the request. Is it a consult? Are you the only person seeing the patient in the ED and you're letting them go? What does that look like? So you want to be sure you're meeting that. What if an inpatient that has CHF with volume overload that are doing LASIKs, would that meet two out of three for high category? Again, it's not really easy to put a congestive heart patient with volume overload. Is that patient having an exacerbation? Is that patient in acute heart failure, they're volume overloaded, but they're stable today? Or are they're progressing, having additional symptoms? If they're on LASIKs, are we considering LASIKs a high-risk medication? If we are, do I have documentation to support why that's a high-risk medication, puts that patient at risk, and that I'm monitoring it with labs? So that one's hard to answer from just a sentence because our congestive heart patients, a lot of time, they remain that they are acutely ill. They have terrible ejection fractions and they're being treated. But today, I might see them, they're on their LASIKs, they are volume overloaded, but they're improving, they're not having any progression. So it's all in that documentation. We can't say specifically based on just that category. Especially if the documentation on our rounding visits sometimes says, patient sitting up in chair doing well, ambulatoring the hallway, and then is it truly describing that picture of that patient and their condition for that day. Can providers choose whether to bill for an EKG separately or not bill and in SCAD count? I would not. I mean, if you are doing an EKG and doing an interpretation and your normal practice is to bill for that interpretation, I don't know if I would bill it towards medical decision-making. I think that gets a little mucky for me. I don't know if there's any guidance out there anyone knows on, but for me, I would say I would not make a choice with that. I think that gets a little complex and one of those areas that's gray and I definitely wouldn't want to give you advice to do that. I would look on your Medicare carrier website. Regarding how to bill consultation services when a patient is admitted to initial observation, when we reference slide 19, if the initial inpatient or observation care is a consult service, the consult service should report subsequent hospital inpatient care codes. Yes. So we were showing the differences, but there were also codes regarding the office outpatient visit service codes. So if I misstated something or caused some confusion, go back and look at the slides, go to your Medicare carrier. Not perfect and definitely don't know all the answer. There is variability across that. If you're the consulting provider and seeing a patient in observation per national CMS and the final rule, it does say if you're the consulting provider and that patient remains in observation status to use the outpatient service codes. Again, not all Medicare carriers have updated their websites and this may stay the same. It was from January and Novotus, so it'll be interesting on if you're seeing denials or what that looks like. But this does impact our physicians, particularly our subspecialties. So you want to be sure that you're getting that clear guidance from your Medicare carrier. There's not a list of parental controlled substances. You can look them up, but again, any list that's provided is not an all-inclusive list. So just remember that when you're looking it up. Can providers count as an independent interpretation when they interpret a rhythm strip? I'm not sure when you're billing that interpretation of a rhythm strip. That's that code 93042. Generally that is not separately billable on the day of an E&M service. It's not separately billable on the day of an EKG. So there's lots to be counted in that. I will tell you, review of telemetry is not considered independent interpretation of a study. And we shared what the wording was on that based on the type of service and what's reasonable and customary with telemetry. This was in regards to the scenario I did about could we meet high risk if the patient was admitted to the hospital for a higher level of service. Again, when you look at those scenarios, what is the documentation supporting? Under risk is if they're considering hospitalization or admitting them to hospitalization. Again, that meets it under risk. Am I meeting it under one of the two other categories, number and problems addressed or data? For discharges, if they don't document time, is it okay to just use the 99238? I would suggest you look at your payer website. I have seen payer websites say that they should document the time. The level of service is based on the time. There's no other component to determine the level of service for a discharge. So time is and should be documented in some form. Again, we are getting a lot of questions. Just to confirm, Medicare is an observation status. We code initial visits, subsequent visits, I'm sorry, initial visits or new patient codes. It's up to your carrier. I told when in the final rule, we've published that on the website in several areas. The actual information from the final rule that points you to the outpatient codes if that patient remains in observation. So again, that's one that you're going to have to continue to monitor your carrier on because there is discrepancy across the board on that one and why we are seeing some of those impacted by that. Split shared and discharge services, APP documented time more than 30 minutes, but the physician didn't. Because of the MD, medical decision-making component, the discharge service was processed under medical decision-making. Well, just what I said, medical decision-making is not a proponent to choose the level of service of discharge. It's based on time. There is no medical decision-making component that would select a level 99238 versus a 99239. It is totally based on time, and there's not a medical decision-making component. So whoever documented would be the one that I would bill the discharge under because they documented the time. A couple of questions about can APPs and MDs share a consult note? Remember, Medicare doesn't recognize consults codes, so those are initial visits. So in that particular example, it was a consultation, but if it's Medicare, they don't recognize consult codes, so that falls under initial visits. And there is some clarification under that, but for Medicare, they don't recognize consults. If lab studies are pulled into the encounter note without any reference made by the provider that they reviewed these, can we still count them? I think there's a lot of disparity there because we can pull over labs from five days at the hospital. Are they looking at those labs? Did they order those labs? Did you give them credit for ordering those labs the day before that they've pulled into the note today because you can't give them credit for reviewing those today if they pulled them in from something they ordered the day before? So I think all of those scenarios, you have to look at the definitions and be sure you're meeting the definitions and that the documentation would support that to an external person. Can an APP see a new patient if it has been more than three years? An APP can see a new patient. The key is if an APP sees a new patient in an office setting, place of service 11, that cannot be billed incident two. If it's billed as a new patient service. Remember, APPs are considered practicing under the same specialist as the physician they're working with. If no time is documented, do you bill a discharge? I think, again, we go back to how do you know what level service of discharge to bill if there's no time document and if it's only based on time and no other components? We're open if you have any documentation around discharges that you've seen carriers post, but it does say that it is a time-based service and that time is required. APPs is around split shared. What if the physician adds the subsequent notes to the original admin or consult note as addendums? They address the status of today's problems but can't tell what they did in any way. Well, again, how do you know they performed a substantial portion of the medical decision making? Is it just from addressing the today's problems? How do you know that they've addressed all of the components of medical decision making and did the substantial portion? Not sure I can tell just from that statement. The most popular question throughout this before we end is around outpatient service codes and observation, which I knew it would be. I wasn't going to avoid it though because some payers are pointing you to initial codes and rounding visits. Some are pointing you to outpatient services. I think you got to check with your payer. Again, they haven't updated a lot of their information. Some of the references I've seen are references from prior to January 1. They're referencing prior to January 1 when you reach out to your carrier because they haven't updated any of their current and will they adopt what was in the final rule or not? I think you got to look for that on your Medicare website. All right, well, we are reaching 230. I appreciate everyone's participation in this webinar and please stay tuned. We'll continue to have information. Remember to use the listserv to share anything from your carrier or any other payer in this space. It's important for us to continue to share as a community in cardiology, so it makes us stronger in knowing what's happening with our evaluation and management services and we'll continue to do that as well. We appreciate your time today and thank you for attending and we'll answer any questions that we did not get to answer in the Q&A format that will be available in the academy.

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Nicole Knight

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