We'll get started shortly, everyone. We're going to give everyone time to go ahead and log in. Well, good afternoon, everyone. This is our last boot camp session. We're going to cover the non-face-to-face coding and documentation opportunities in cardiology, cardiovascular care. I'm joined by Linda Gates-Stribbe, which most of you all know. Linda is still with Ascension in Indiana. She also is a consultant with the revenue cycle team and we are happy to have her with us. She's going to cover the first part of our session after I go through a couple of housekeeping slides. If you have questions throughout the presentation, please be sure to type those in the Q&A button. All of the revenue cycle team, we are monitoring that box and Linda and I will take some questions at the end as well. We ask that you try to keep it on topic as much as possible, but feel free to enter those questions. If we don't get to your questions, we will answer those and they will be uploaded and available for you to see as well. In the chat box, you'll find the link to the presentation. This is where you can download the presentation and the slides so that you have them. That'll be in the chat box. CEU certificates, these are available for these webinars. This is 1.5 for today. You'll be able to download those from the Academy site. This is a reminder of those directions on where you can claim those CEUs. Before I turn it over to Linda and I'll let her chime in a bit on what they're thinking of doing in this space, but many of you might have seen the traffic on e-mail this morning and yesterday around that some of the extensions for telehealth, also the reprieve for the conversion factor. Some of those things had originally passed earlier this week with a vote. Then we found out yesterday evening that that's been squashed and all of the votes are taken back and we're still in a holding pattern. You may see some media where it's saying that telehealth's been extended two years and that the conversion factor was increased 2.5. But we've been told that that is on hold again, and I did see some of the news outlets posting that that is on hold as well. We're back to square one. Linda, I'm going to turn it over to you. I don't know if you want to comment what your groups are doing as we get started. I'll talk about poll questions. What are you-all doing with telehealth? I know that's been the big question lately. Yeah. Well, we're in that what do we do at this point? You want to think that this is going to go through. It feels like this train has left the station. It's going to go through, but is it going to go through by January 1? We had people saying, so what do we do? Do we cancel? Anyone that's Medicare with a virtual appointment in the first week, it's like, no, we don't want to do that. Are we risking that it may not be covered by January 1? Maybe the vote will occur later and go retro to January 1. We just landed on, let's absolutely minimize the telephone only, because we know those existing telephone only codes were deleted and Medicare said they're not going to cover those new audio only. It's like, okay, we haven't heard of a commercial payer who is committed to using and accepting those new codes for the virtual and or audio only. We're basically just saying, until we can communicate further, just do what you're doing now and we'll just get started and wait and see. We don't feel like we want to jeopardize the care that the patients need, and just moving forward on good faith that they'll get it all figured out. Yes, we can all hope so. I agree with that. I think limiting the audio or telephone only, and then not necessarily inconveniencing all of the poor patients who are trying to access to care is the way to go. Before Linda kicks us off, just want to go over, we have about three poll questions throughout the presentation. Once the poll is launched, you will answer the questions and hit submit so it'll pop up on your screen. If you accidentally close the window before you submit, you can click on the poll and quizzes button, which is located near your Q&A button, and the results will be displayed after the poll closes. We felt like this was going to be a good way to get you guys to interact, and this is something we're going to trial through this Academy webcast, and I think if it works well, it's definitely something we can use. All right, Linda. Well, thank you and welcome everyone. It's great to be here and see so many familiar names and such. What we wanted to do in this session was really think about what are the things that we're doing that we may not be submitting charges for? What are the things that we may like to do, and if we could find a way to be able to produce an ROI and show that, not only is this a value add for our patients, but it's a value add for our revenue. We wanted to focus this session on challenging everyone to maybe think a little bigger, a little broader. What might you do if you could get it reimbursed? I can give you a personal example that at one point, we had lipid educations. We do that in a group. We also had a CHF with a dietician who would just have a session to show people how to read labels on a can, look for those things, watching your sodium is more than taking the salt off the table. If there are things that we are already doing or we would like to do, could we potentially fit them into one of these scenarios that would allow us to actually be reimbursed for that? What we see is often things are being done. We all know our nurses and our physicians end up spending considerable amount of time on the phone with our patients. But that's often with a patient asks a question and now we're responding back. But how many of those could we maybe get in front of so that we then call the patients? What I've found is if you get a room of maybe your heart failure physicians as an example, if you get them in a room, get the physicians and the patients in a room and say, what are the most frequent things that you're needing to do? Do you have patients that you just know you're going to hear from every week? You'll usually have all of them saying, oh, absolutely, there's this one and this one. That's what we're talking about here. How can we take that and find a way to actually capture those services? We know that there are things that of course, when we tell the patient they need to come in or we schedule a virtual visit. But what are some of the other options we have? That's really what we want to focus on today and just challenge ourselves to think a little broader. Go to the next slide here. I know that we've heard some of the new things, but I want to make sure everyone's aware of this one, the social determinants of health. At first glance, you may think, oh, but this is primary care. Well, I would say not always. I think we know that we find patients who are unable to afford their medications. As a result, we're working with the drug company or someone to try to get their medicines to them at a reduced rate. Well, that's a perfect example of how we might fit that one particular activity into something like this. This G-code, you can see that it's the administration of a standardized evidence-based risk assessment, five to 10 minutes, and we can use it once every six months. The next piece is key, that when you find that social risk factor that is influencing that patient's health, that diagnosis or treatment of their condition, that's what we're talking about. Most of us are doing some quality metric where we're already going to be doing a social determinant of health risk assessment. The MA or whoever's checking the patient into the room, they're going to ask those series of questions. That's not what we're talking about here. It's once they've asked those questions and they identify something, and what that is that they're identifying is impacting that patient's condition. Let's say, for example, it was as they're checking them in, they've done their risk assessment, they've asked all their questions, and then the patient, when they go to verify their medication, says, well, actually, I've been breaking this pill in half. I can't afford it. You just found that the patient cannot afford their medication as prescribed. As a result, their blood pressure is not controlled as prescribed, and you just met the piece of this. Documenting that, and then we need to have five minutes focused on how to resolve that. You can see that on the third bullet there, when it talks about an evidence-based social determinative health risk assessment and standardized tool. Originally, Medicare had proposed a specific tool. They said, and this is the tool that we want. But in the feedback that they had from the proposed rule, they actually ended up saying, okay, we're not going to name the tool. As long as it's a standard assessment, that's fine. And then you see in the yellow highlight there, said, but that standard assessment absolutely must have these four things. So, they need to make sure that we're checking for the food insecurity, housing, transportation, and utilities. So, from a documentation perspective, what they're looking for is, what was the social determinant, and what is the health condition that's being impacted and how? And then, of course, it's a time-based code. So, when you have a time-based code, we're going to need to document the time as well. So, go on to the next slide there. So, you can see, you know, this is a standalone code. It would be added on top of the E&M. So, at the time that you identify this, maybe through check-in, or maybe it's not until the clinician is in the room with the patient, but as soon as they identify this, now we add this standalone code. Now, you can see there on the right-hand side, these were the sample tools that CMS ultimately ended up saying, you know, any of these, for example. They're not the only options, but you would just double-check that whatever you're doing does have those four elements and is a standardized assessment or tool. Now, Medicare went on to say, we would love for you to use the Z codes. Now, those Z codes are really helpful because they're going to name what the issue is. You know, that allows them to now track those patients. You know, they can see, okay, who are the patients who are having transportation problems, who are having... So, they are saying, we would love to see the Z codes. They're strongly encouraging it. You can see the work RVU of a 0.18 and reimburse it $18. And if you use the Z codes and attach them to the G code, now that allows them for tracking purposes. So, what they put out, if you go to the next slide, they really did a nice tool. It's a good at-a-glance tool, and it lists a lot of those very frequently used Z codes. I can tell you for our pediatrics, the pediatric cardiologists and such, having that contact with tobacco smoke. You know, maybe that's really impacting that patient's breathing. You know, that they are all the way around. They're always around that. So, having that conversation. There's some other ones, as we talked about before, go on to the next slide. If the issue is with medication and or maybe with diet, you know, you have all these other Z codes as well. Maybe the reason that they can't get their blood pressure down or under control or their heart fail is they're not following their diet. Well, maybe they're not following their diet because they have food insecurities. And so, you're hooking them up with, you know, a food pantry or something that might be able to help them. You can see we can communicate that via these Z codes. And then you see there the intentional underdosing due to a financial hardship or some other reason there. And there is another set of codes where it's not the patients intentionally doing this, it is the caregiver who is doing it. So, maybe it's the spouse, the son, the daughter, who's taking care of mom and dad or mom and dad taking care of the child. So, there is another code series to say it's the caregiver unintentional. So, I think this is a good way to think about it and just maybe starting there, you know, ask your clinical team, how much time do you think you spend on average working with patients who can't afford the medicines, working with patients who have food insecurities and helping them with that? If you're doing that, then you probably are meeting the definition for this code and maybe more. It is billable per clinician once every six months. So, maybe the primary care doctor, you know, addressed something, but now you're doing something different. You would each be able to bill it, but you can't bill it more than once every six months. So, just have those conversations, see if you really are working with patients like this and meeting that minimum time and could potentially be adding that code. I see a question that it requires documenting patient consent. That is not correct. It is just a matter of documenting what's the condition and what's the hardship. Now, that's a good segue into our next topics because now we're gonna talk about some things that you do want that. So, let's think about this one, caregiver training. When this one came out, it's been a couple of years now and it's getting expanded yet again. It was thought that this would be something that maybe the physical therapist would do, working with the patient or their family on transfers or how to move around the house without hurting themselves or looking at their environment and such. But look at the third bullet, chronic illnesses or disabling conditions, short or long term, involving episodic, daily, occasional basis, targeting symptoms, influencing functioning adherence, understanding. What is it that we might be doing? And there are codes here for either the group or an individual. So, what are the educational things, services that are being rendered? What might you be able to do one-on-one and or in a group setting that could benefit? And you can see the work RV use and such there as well. So, I think again, it's just a matter of, let's broaden our minds. Let's think about, what are we doing? What do we do? What would we like to do if we had a way that we could actually justify it? We could do it, but gosh, there's not many of us with enough room in our budgets to add things and add people that we expect we're not gonna get reimbursed for. So, we're really looking for where does the best interest of the patient coincide with we have the people or could have the people to begin offering these types of services. Let's look at the next slide. So, let's think about our nurse visit. I know there was a time when, if we go back 20 years, maybe even further, that people kind of got in the habit of billing a nurse visit with every pro-time check. And then it came under significant focus and it's like, oh no, no, no, no, you can't do that, you can't do that. Well, you can when there is a significant and separate, in most cases, the education with the patient that necessitates that interaction with our clinical staff. So, let's remind ourselves of what that 99211 is. Whether it's your meeting with the patient and for now, it can be virtual. So, we know that those flexibilities have been extended by CMS, even though the home-based coverage can't. So, that leaves us in this gray zone for now. So, let's just keep it as what's gonna need to be face-to-face, knowing that if and when this gets finalized and extended, now we know rock solid. We could have our nurses doing virtual visits with our patients. So, face-to-face, maybe virtual. We're gonna bill that under the physician's name and the 99211, that doesn't require a patient consent. I think that what we need to do is just make sure that the patient understands that when we say we're gonna schedule a visit with the nurse, that's not just a phone call. So, we can't do a phone call. We can't bill for just the fact that the nurse is gonna call the patient back to answer a question. We're gonna talk about some alternatives there that involve care rendered over the phone, but it's certainly not a 99211. You know, we have to have them know. So, medical necessity being the key here. You know, what is medically necessary? Is the physician saying, you know, okay, I'm gonna have the nurse set up a time with you and I'm gonna have you discuss what your blood pressures have been this week, what your daily weights have been, how your symptoms are. And you know, you set that up as the patient's checking out maybe. I mean, there's ways that we can think about what is it that our folks are doing on the phone and could or should any of those actually be a scheduled visit that we could do virtually. And or maybe they're coming back into the office and saying, you don't need to see me, but I do want the nurse to, you know, check your blood pressure and make sure you're doing okay. So let's, you know, thinking about it in that manner. Go to the next slide. So I don't know if you're aware of the MedAxiom Heart Talk podcast. We do have a slide towards the end that tells you exactly where to go if you'd like to listen to them. They're all like maybe 20 minute little little sections and it's Nicole and I discussing a particular topic and along with every session is also a sheet that you can download. So here's the view of when we recorded our 99211 pod heart talk. So you can go in and listen to that, download the sheet, it gives you you know what are the some of those potential use cases, you know what are some of the key pieces as well as then implementation thoughts. So I think let's let's consider the 99211 and are we taking advantage of using it when we could and should. Next slide. So just you know general implementation tips. I think number one just making sure that patient understands that when we say we're going to schedule a visit with our staff that they understand it is a scheduled visit and if you're going to do that virtual then both both your clinician and your medical staff could be an MA as long as whatever they're doing is also in their scope of care doesn't have to be a nurse but scheduling that knowing that this is going to generate the charge, make sure that our documentation is there to support the medical necessity first and foremost and then the nature of what you're doing. We're not going to use it for just routine things you know I think that everyone knows by now that you can't just have the patient come in for an injection or their pro-time or their you know a blood draw and just throw a nurse visit on there I mean where's the necessity there you know so medical necessity is key and some of our carriers do have medical policies that they've published on 99211. CGS and Meridian are examples of a couple of carriers that actually have really nice policies so if you've not seen those you might want to pull those and just take a look at it. Next slide. So Nicole mentioned that we were going to have some poll questions so I think it would be nice if y'all will take a look at the poll and select any of these that apply. You know there's we talked about different ways we can do it I know a lot of people are bringing on pharmacists and the pharmacist to review and evaluate and discuss that patient you know are you are you trying to do education and counseling on lipid management with a nurse you know a scheduled time. Maybe you're calling the patients a couple of days after their their intervention saying hey show me your wound you know let me see what your access spot looks like. And another use case we know our clinicians get bombarded with portal questions maybe we're not building those portal encounters yet but have you thought about telling the patient you know this is a really in-depth question and is outside of the scope of an email I'm gonna ask you to schedule a visit with my nurse and she can go over this with you. Or maybe there's just that hypertension or heart failure different pieces here or maybe you're just not using it or you've gotten some ideas from this and you're going to be talking about it. So I don't know when are you able to show us the poll or? Absolutely we got a couple more questions coming in maybe give it another 10 seconds. All right perfect. Oh the suspense. The suspense if it works right. Yeah let's see if we can make it work. You're all part of our big experiment. I do see a question here saying it's it's the way we're talking about it blurs into CCM. Oh yes it does. Good segue into our next question. So let's see what those poll results look like. Here they are. All right wow we got a pretty good variety there. Yeah still got about 30% not using it so. Yeah okay so routine follow-up on heart failure and hypertension that's looks to be number one there. Yeah there's not using it. Education on pro-time management. Okay well that's that's interesting. I like this and I'm seeing some other questions saying okay we do some other things on the same day use the modifier 59 and you know so I think you know we just really need to think about this and I think this is a great segue to go into you know all right so we said 99211 cannot be used if all it is is on the phone. So I think you know back to the question that says okay so this is blurring into chronic care management or or principal care management. What what are the differences? Well here's the first difference. The 99211 cannot be telephone only. You're going to have to be virtual and or have the patient come face-to-face. If what you're doing is only telephone based now we're heading into those categories so that's what we're looking at here. So you know here we do have options and as we'll talk through them is it your clinical staff who's on the phone or is it your clinician? You know are they the ones that are on the phone? It might involve face-to-face. It could be just telephone only and now you know we talked before and I think someone asked the question about a consent. Now these next category of services they do require a patient consent. There's another difference between you know what we're going to talk about now and that 99211. The 99211 is just a visit. You already have consents for visits at the time that the patient presents to you the very first time. So you know I think it's a matter of sort of matching what we're doing to the service that it most closely links to and then double-checking that we're meeting all the requirements and the documentation. So you know we are going to have to have that care plan making sure that they know that these phone calls that we're talking about are going to roll up into a billable charge. So that's why that consent is an element that you get that consent first so that we've told them you know we're going to keep a closer eye on you. You know we're going to be contacting you each month. Now depending on the condition the patients have and who's providing the service and how much time you spend it's going to put you down the right channel to say which of these phone based services are we talking about here. So you know there's that defined minimum time. There's also codes that are add-on. So if you meet that minimum time and you're now exceeding it well you need to wait and hold that charge and say by the end of that 30-day period have we exceeded it enough to drop the additional code. And then there's an additional code for one even for the physician having that discussion with the patient and saying you know this is your third admission in six months. We need to keep a closer eye on you. I'm going to enroll you in this chronic care management services. My nurse is going to come in and talk with you about that. Just that little comment that little conversation right there is the charge that the physician adds on that day for placing the patient under chronic care management. Go to the next slide. So we're going to talk about maybe adding this but you can see we have another poll just to get a feel for where people stand now. Principal care management, chronic care management, complex chronic care management, or we just can't seem to get these off the ground, and or we're going to be discussing this with leadership. So take the time now to click these. I'm really curious to see what people may be doing in this space. And Nicole I know you mentioned that you're seeing some changes throughout the MedAxium members. You want to tell us a little bit about what you currently see or beginning to see while we have those answers coming in? Yep we are seeing programs looking at and exploring and even implementing chronic care or principal care management. I do believe cardiology has an opportunity particularly in principal care management and Linda will cover that now but these programs I believe are continuing to grow in the organization and often also have remote patient monitoring which we'll be covering. So we're seeing these from a perspective of groups trying to align on a central virtual care center approach where they're able to offer this type of access for their patients. So really doing some standardization, creating a team to operationalize this and seeing a lot of success in that. So we we had a couple of presentations at our fall meeting that are available on the website but we are seeing that across the membership. Excellent. What do we get? 30% saying we're going to talk about this. Hey I'm 51% with chronic care management. Excellent. 17% we can't seem to get them off the ground. Me too. We're we're struggling as well. We've got a handful that are doing it really well and we know we're rendering the services but we just can't seem to to make it all pull together. So let's let's look at this on the next slide and make sure we understand what we're talking about. Oops go back one. Okay so I tried to kind of put it at a glance because I want to highlight some of the things here. So you'll see at the bottom each of these requires the patient's consent and then now look at number two there. For principal care management we just need that single high-risk disease. Chronic care management two or more chronic conditions. Complex chronic care management two or more and high-risk. So we're gonna slot the patient into these based on what are the medical conditions that we're addressing. So you know we saw pretty heavy management there with chronic care management. So let's look at the center. Let's look at that first. They're in the chronic care management. You'll note that there are clinician codes. So when there are clinician codes this is you know if your doctor gets on the phone with that patient for 10 to 20 minutes or whatever the case may be that month. We want them to know that the patient is enrolled in this program. If they hit that 30 minutes minimum and you'll see whether we're talking chronic care management and or principal care management for physician time it is 30 minutes. I can tell you we did have success in rolling this out with one of our pediatric oncologists. You know his comment there was I have a number of patients where I am absolutely doing that and so it's like okay let's let's try to get this off the ground and we were successful in doing that. But now look at your clinical staff. So let's go down. If you're talking chronic care management you can see that one is 20 minutes a month. Well gosh one conversation might do that or maybe two. You know two 10-minute conversations and you've just met that requirement. So we saw that that was the one that that more were using but let's look over at principal care management. So the principal care management does take only the one chronic condition but it does take 30 minutes. So you know if you if you have that patient that only has one and you only spend 20 minutes in the month you're not going to meet it. You know so looking at what are we trying to do here. Are we are we single condition two or more and if it is two or more well then now how much time are we spending. So if it's two or more that are really high risk now look at your complex chronic care management. We've got the clinical staff time of 60 minutes in a month. So that's why I kind of like this at-a-glance view because we're looking at where does the patient's clinical condition slot and then how much time have we spent in that month. So there are those differences here. So go to the next slide and if you've not taken a look this was the May update. It's the chronic care management services all in one nice put-together resource. So it talk goes through taking you through all of this and each of the services that we just spoke about are all covered within this with this booklet. Go to the next slide and as you get into that it does go through and say okay so what are the types of conditions that we believe would qualify and you can see there's a nice list there. It's certainly not limited to that. Most of what we do in in cardiology is going to slot in under these. It talks about you know the fact that you're going to need to see the patient first and and the physician is going to need to enroll them into it and then what does the documentation need to reflect. Well you can see the care the the g-code there that's the one that the clinician would bill at the time that they start that conversation with the patient and say you know we're going to follow you. We're going to do it for as many months as is potentially necessary until we see that you're feeling better and that that this medication is working well for you and we just want to make sure that you know we get you get you stabilized and feeling well and you can see there what the documentation should reflect where you've got that comprehensive assessment then that detailed care plan that talks about you know what are the specific interventions and services to be provided. What I'm thinking would be the easiest thing to do is say okay for heart failure or you know hypertensive crisis and maybe symptomatic fibrillation some of those things you know we already have the physicians know what those care plans look like. They know what it is that we need to do we probably just need to formalize it a little bit and then customize it to that patient so that okay we're going to confirm patients you know responded with the medication. Tell the patient we're just we're gonna schedule a call with you what day of the week generally works best. Is there a certain time of day we're gonna call you every Thursday at 10 o'clock and see about your blood pressure and your symptoms and your weight. This is part of that chronic care management we were telling you about and now you just document those following that sign so I think you know coming up with a template that meets most of your needs and this is where it really it takes that combination of of the coding being involved having you guys in the room but getting your clinical leaders and a physician champion you know get you all in a room and say okay what kind of things are we already doing it's like what we do this all day long okay let's let's let's get some examples let's formalize it a little bit where does it fit does it go into we should be scheduling you know a virtual 99211 or should we be enrolling these patients in principal care management or chronic care management there's nothing that says that once we enroll them that we have to do it each month I mean we want not it might not be medically necessary to follow that patient for more than two to three months or we might have those patients that would really benefit with that ongoing support just just constantly reaching out and making sure that they're doing okay making sure that they're bringing up that you know they don't feel good rather than waiting for an appointment that may be scheduled six months away next slide so I think you know use this booklet and if we look at principal care management you know there there we there we saw that you know it seems almost counterintuitive that the principal care management needs the 30 minutes and the chronic care management the 20 it seems like it'd be the other way around but you'll find this on principal care management in that same document you're not going to build until you know you've met the time requirement for the month so you're gonna wait and then you really want to wait the full 30 days because you don't know at the time that you met it that you're not going to end up exceeding it so I would suggest that you hang on to it and hold it and this is something that you can do whether you're a hospital outpatient department or a PBB or a physician office either of these and this is one where you can even contract with somebody to do it you could have a nurse who does nothing but work from home and makes these phone calls all day every day you know they don't even have to be in the office with this one so I think we just need to broaden our thought process what are we doing what could we do and then be able to produce you know the the ROI on it Medicare has already said they noticed a significant correlation between patients who are enrolled in chronic care management and a decrease in hospital admissions that's what we're all after that's one of the reasons why you know Medicare has made these services a little easier and a little easier to provide almost every year they make a little tweak you know so if you haven't you know gone back and talked about it thought about it discussed it you know it's time to revisit it and and see if maybe you do want to start thinking in line with some of this stuff next slide so you know of course any of this documentation and and that is one of the hardest pieces and as Nicole referenced earlier at our fall conference we met with a couple of pod groups and talked about this and the administrators and physicians were like wow we hadn't thought of it that way what a great idea you know we need to be doing this and then as we talked about you know the these pieces that you know what can make difficult is how do you monitor it how and where do you document it how do you know that you've met the time to bill and one of the administrators spoke up and said no epic has a perfect method for how to track this it's really easy great I can tell you we're on Athena and we sure don't have an easy way to do it so just knowing you know how are you gonna how are you gonna track it monitor it time it document it you know who are those patients you know think through you know everything that you see here on this slide and figure out you know how are we going to get this and how what are we tracking under next slide I put this together when I had a practice reach out to us and say, we have a social worker who is spending a lot of time with the patients. We'd like to do this more efficiently. And what are our options going to be? And so this is just another way to kind of look at it as you're having those discussions with what are we doing? What would we like to do? Figuring out also who would be doing this? Is this the pharmacist? Is it an MA? Is it a nurse? Is it a social worker? So you can think about it in a couple of different ways, you know, starting on the far right-hand side, who is it that would be providing whatever it is you're thinking about? You know, is it one on one? Is it somebody who can separately bill? Are they going to have to work under incident too? What is it that you, that you're talking about? Is this individual education or, you know, patient specific, you know, so you can kind of think about it this way, you know, you, you could do a group education on lipid management or heart failure maybe once a month. And would the patient be present or would it be their spouse? You know, the person who's doing the cooking, you know, or whoever's helping take care of them. So you can kind of use this and, and figure out which way is going to best match your conversations as you think through this. Next slide. All right. So I'm going to hit you with two more ideas a little briefly and then turn it over to Nicole. I think we are all after, I mean, when we had those fall sessions, I, I mean, you'll, you'll hear from all the revenue cycle folks and your leaderships, the clinicians, we know they're overwhelmed with, you know, pajama time services, you know, documenting paperwork and, and just those electronic emails and portal messages. And so wanted to mention, and I'm just going to briefly, you know, bring them to your attention. I'm not going to spend a lot of time here because we do have one of those recorded heart talks on home health certification. It's just as simple as asking the clinicians, are you being sent things to sign off on home health, certifying a patient's home health? If we're signing off on that and sending that order back to the home health company, that is a billable service. So I'll go to the next slide. You can see the code and you know, really Medicare is willing to reimburse for this and wants to for that initial certification as well as the recertification because there are so many problems with that system. We, we hear about, you know, fraud and different things that are being baked into this. So it's just as simple as, are you receiving these and are you signing them? If you're signing them, you need to find a way to drop the code. It's, it's that simple. I say simple, a bit tongue in cheek because you know, how does that request move through your practice? You know, how does it come in? How does it go out? How do you route it or do something so that you drop the charge? I mean, it's, it's that simple. It is a reimbursable service. Next slide. So we also have interprofessional consults. Now, you know, these, I don't know if we went two slides there, Nicole, there might've been one right before. Yeah. So, oops, there. Okay. So this came about in our group, we started using it in the early days of COVID. Our infectious disease physicians were just getting slammed as you all will remember. There was so much that was unknown that they were just getting stopped nonstop. They couldn't hardly see patients for all the questions they had from others. But you know, the more we've thought about this, it's more now the cardiology locations and they're the ones, as we talk about, what are those things that you're doing that you don't get any credit for that's taking your time that that is a required, you know, clinically necessary function pre-op clearance. So we did a couple of years ago, roll this out in cardiology. Now I want to point out, this is not replacing the need for a visit. If that patient needs to be seen in order to have that Clark cardiac clearance, and they absolutely will be seen. But with some patients, it really is as simple as the ophthalmologist or the dentist, or someone just needs the cardiologist to say, yes, it is okay for them to undergo that procedure. Well, that's what we're talking about here. Next slide. So now you can see, um, actually the slide didn't change yet on my end. There we go. So these are the codes and think about them in that potential pre-op sign off where it is simply a form. We are meeting the requirement here. You know, there, the, someone is asking for our opinion or advice. We're sending that back. Now this one, there is a patient consent required. So you need to know your patients, uh, your organizational stance. Lots of folks say, well, that's part of the consent woman. They just consent to care in general. Other compliance areas have said, no, we want individual for this service. So there is a consent required, but predominantly, uh, this has felt to fall under the patient's general consent. Go on to the next slide. So I want to point out that there are a couple of sets of codes here. So the first ones you'll see are time-based codes and that involves both the report back and a conversation with the requesting. So we're not going to put those in, in the conversation today. We're going to focus on just that last one. That's the written report only. That's the review of records, responding back, adding the information and it's dropping a code. Next slide. So this is, um, on the left is what one of our managers wrote up for how, you know, cause you have to know how those requests move. You don't want to jeopardize the fact that, you know, however they're moving around through your practice now, they still need to get there, you know, coming in from the surgeon, getting back out from the surgeon. Is it a fax? Is it being routed electronically? You know, which way is it going? So we, we had to come up with a couple of different ways. In some examples, we use our form and then put information on our form and others, you know, the, the person's requesting that has a form. We did have to note and add the time. You'll see that on the bottom right on the right hand side to our form. And then we had to figure out how do we internalize it in, in the way that it flows. Next slide. So what we landed on was, you know, we're already putting a comment in and you can see that, you know, where the arrow is pointing is just a matter of putting that, that time in there. There is a minimum requirement of five minutes, but it doesn't take five minutes to review that, that chart at a minimum, then it's not billable. So it is a time-based code, time needs to be documented, but then how do we actually now drop a charge? A lot of our systems are encounter based. So if we don't have a visit to put the charge against, then how are we going to actually get this back to where we can drop a charge? You know, it's just going to move on through our system and out it goes. Next slide. So we had to come up with that. It would be routed back to the nurse and then our nurse creates a form. And this is the form that was created and shared on Google where the nurse starts it out by putting the patient's last name, first name, date of birth. We've got the CPT code. We've got the primary surgical clearance, who it went to. Now the time is what the nurse fills in. So the nurse adds the time as documented by the doctor. There's our first check. If it didn't, if it wasn't documented, can't bill it. If it doesn't have at least five minutes, can't bill it. And then now the billing person has everything they need to go in and drop the charge. And then they just highlight them on this log as they do. So it's worked really well and it's a huge physician satisfier. Next slide. So here's what we were talking about. If you've not gone to the MedAxiam hot talk, our heart talk on hot topics, you'll see ones there for the 99211, the home health, interprofessional consults and others. But I will turn it over to Nicole and let her share some additional information with you. All right. And sorry, we will have time for questions. I'm just going to go through briefly remote patient monitoring. And we have one poll question left and then Linda and I will jump into the questions that you're sending through. All right. So for remote patient monitoring, this is an area where we've seen many programs have adopted remote patient monitoring programs. When we talk about RPM services, these are the ones that involve the use of non-face-to-face technology to manage and analyze a patient's physiological metrics. And in our world, this could be oxygen sets. This could be blood pressure, blood sugar, blood oxygen levels, weight loss or gain. The RPM information is transmitted electronically and is not self-reported. There also are some codes out there that are considered RTM, remote therapeutic monitoring. This is non-physiologic data. It usually includes the data on musculoskeletal or respiratory status. So the category we're going to focus on is the RPM. I just wanted to provide the definition in case you are using those codes, if you have other specialties or you're doing some sort of respiratory non-physiologic monitoring, you may be using the other ones. The difference, the big difference other than the definition is that RTM may be self-reported by the patient. So those codes are definitely different than the RPM services. So here are some of the health conditions that may be used. This is not an all-inclusive list. We've seen hypertension, heart failure, obesity. We've seen a couple of different programs who've launched this. Also COPD, diabetes, vertigo, syncope. Again, not an all-inclusive list. Some of the types of devices that we're seeing in the RPM space or the digital scales that transmit data to the program, heart monitors, blood pressure monitors or oxygen monitors. The RPM requirements for CMS Medicare is that the patient is an established patient. So they have an established relationship with the provider. It does require an interactive live communication with the patient at least 20 minutes per month. So another time-based service. The data must be collected for a minimum of 16 days. So you have to have 16 days of data transmitted out of the 30 days in order to bill for RPM services. Only one practitioner can bill for RPM per patient in a 30-day period. And again, these are consent codes. So very similar to the categories Linda covered. The physiological data must be transmitted electronically and automatically uploaded to a secure location where that data can be available for analysis and interpretation by the billing practitioner. So for RPM, it does have to be automatically transmitted and it has an analysis and interpretation component by a practitioner. Also, there's a link on this FDA where we talk about the FDA, the device that's used to collect and transmit the data has to meet the definition of a medical device as defined by the FDA. It can be billed during the global service period. And then also our rural health clinics or any of our federally qualified health centers can receive a separate payment for these services. It does require an order and medical necessity for these services. So these are our CPT codes that include our work RVUs and the National Medicare Physician Fee Schedule reimbursement. The first code is that initial setup and patient education for use of the equipment. The 5-4 is the device and supply with the daily recordings or alert transmission each 30 days. And then the 5-7 is that 20 minutes of time that's spent by the clinical staff under the guidance of the physician or practitioner in the interactive communication on their remote physiological monitoring treatment and management services. And then there's also an add-on code for additional 20 minutes that can be added during the month with the primary procedure of the 9-9-4-5-7. There is a caveat that when appropriate, you can also bill CCM, PCM, TCM, or any type of behavioral health integration. The key with time-based services and any of these programs is you can't double count your time. So the time you count that's related to RPM is billed as RPM. The time that you participate if it's in chronic care management or principal care management is the time that you count towards those programs. So you can't double count RPM time for RPM and CCM. And it's very important if you have multiple programs and patients who are on both programs that you have a way to distinctly do that in your organization. So here are some considerations to RPM. The clinical staff can furnace and manage the RPM under the general supervision of the billing provider. Consider how the documentation is completed and available. Same thing around your care management programs. How are you tracking time? What does that documentation look like? Are you meeting all of the requirements of the code, consent, all of those things that are required? Do you have that live communication or interactive communication with the patient? And are you meeting a 20-minute threshold for the professional service to be billed for the RPM? Who's performing and billing for what components? We often see this because a lot of times the technical portions of RPM are outsourced and the physician is or the program is billing for the professional services only. So you want to be sure who is billing for what components and what that looks like in your organization. And again, the overlap, you do not want these programs to overlap where you're double counting time. So interesting enough, when we were putting this together, they just posted this was published in September of 24. The OIG did some investigation or reviews within remote patient monitoring. And I found some of this information very interesting. So they did this review because it is a potential to greatly expand, as we know, our digital, our technology, all of this is expanding. As a result, it's an increasing need to know how it's being used, who's receiving it for what conditions and any vulnerabilities that may limit the oversight of these services. Some of the things they found was that the use of remote monitoring increased dramatically from 2019 to 22. I don't think that surprises any of us because obviously during the pandemic, I think remote patient monitoring, that was the biggest kickoff and when it peaked for sure. And as programs continue to utilize this through many of their clinical management programs, et cetera, we're seeing growth. About 43% of the enrollees for remote patient monitoring did not receive all three components, which raised questions. So what that means is so they received the initial setup and education and potentially didn't have a transmission, potentially didn't have the 20 minute professional service. So 43%, that was pretty high that they didn't receive all components of it. So obviously if you're enrolling a patient and you're billing for the enrollment setup, you would think that you would have a billable remote patient monitoring session that would include the professional technical component at least once. So that was a bit surprising. And then does this raise some concerns about some fraudulent activity and Medicare lacks some key information on oversight, including who ordered the monitoring. Ordering is very important. Do you have an order to enroll a patient in remote patient monitoring? I see this on many of our Medicare carrier sites as well. So be sure that if you are doing remote patient monitoring or considering it, that you are getting a order for that patient to be enrolled in remote patient monitoring. So patients for remote patient monitoring in Medicare were more than 20 times higher than in for just four years, which no doubt that we're going to continue to see that path. So the OIG recommends for Medicare to take the following steps to strengthen the oversight. So implement some safeguards to include how it's used and billed appropriately, require RPM be ordered and that the information about the ordering provider be included on claims and encounter data, develop methods to identify what health data is being monitored, conduct provider education, identify and monitor companies who bill for remote patient monitoring. And I think we'll see more in this space. I think it's good that we're getting some oversight in this area and hopefully we'll get more direction and examples and maybe an MLN or an RPM that'll help us for CMS because there are a lot of companies out there. There's different types of monitoring. There are different types of devices. I don't think anyone should be afraid of utilizing remote patient monitoring, but I do think it's important as any of these services, particularly if you're involving a third-party company, that you are checking your boxes and knowing exactly how the service is being provided, billed, documented, transmitted, all of those things to be sure you're meeting all of those requirements. All right. So our last poll questions. So some additional services. We want to know if you are currently billing for the home health certs or recerts, interprofessional consults codes, and will you be discussing with leadership? I think on the poll question, RPM might have gotten left off, but that's no issue with that. Just check the box on those two and we'll see the results. Thanks for that. Linda and I'll start looking through the questions as well. Yeah, that's what I've been doing. There's a lot of good questions here. I'm trying to type in some answers. Yeah. Ari, do you have the results? Sure do. Here we go. All right. So pretty good. The 24 to 29% are doing 24% home health certs, 29% the consults and 58% are going to discuss it with your leadership and I believe that's great. So I'm going to get us to the Q&A part of the session. It's interesting, I see Linda's typing on this question, but I thought this was a fabulous question. Is the use of G2211, which is our add-on complexity code, would this be an identifier that the patient would be a candidate for chronic care management or principal care management? So Linda, what was your answer to that? Because I think that was a great question and something to consider for sure. Oh, yeah. I mean, and it really was a good thought on whoever asked that. Just because they've added it, I think that doesn't tell us that, you know, they don't go automatically hand in hand. But that's saying we have that ongoing relationship with the patient. I think it comes right back again to what is the medical necessity. Is there something going on with that patient that says we're going to do something in between now and when we see that patient again? Is there a medically necessary reason for us to now have contact with that patient or to follow them or to do something more? So I like the question and that's my thought. You know, as with all of these, the medical necessity of what we're doing is the driver. And before we consider any billable question, we've got to go back to what's the medical necessity. Yes, absolutely. And Linda, on our 99211s, that first question. So I know we talked a lot about the nurse visit or what we call the nurse visit. Could an MA be providing that service as well under that general supervision? What's been your experience with that? Absolutely. Yeah. And what it goes back to there is nature of services being rendered. And does it fall within the scope of care of that person? You know, if we're talking about, you know, getting into some in-depth education on anticoagulants or, you know, heart failure medicines, you know, that is probably better suited for a nurse than an MA. But calling them and saying, you know, what's your blood pressure been? What's your weight? How are you feeling? Did you get your prescription filled? When did you start making those changes? So I think there again, it doesn't prohibit the 99211. Absolutely could be an MA, but what's the nature of the service and who's the most appropriate to be doing that? Can they be calling the drug company and making arrangements for that patient to get discounted samples? Absolutely. Are they doing that because the patient couldn't afford their meds and didn't fill their prescription? Was that a social determinant of health? Probably so. So, yeah, I think we just really, I mean, I hope that, you know, what you're taking away, and I was thrilled to see that so many people are saying that they're going to discuss it with leadership. I mean, that's exactly what we were hoping to hear, that we're kind of opening our minds up again and figuring out how can we on the coding and billing side, help our patients by helping our clinicians. And then, you know, seeing some of these things that are truly revenue producing, I mean, it's a win, win, win. I did see a question and answered it about co-pays. Patient co-pays are there, but keep in mind that if the reimbursement, for example, is $16, Medicare is going to pay 80% of that, you're going to get it down to $3 to $4, and a lot of those patients have a secondary. So, yes, there wasn't a service that we talked about today that is exempt. You know, it's pretty much only the preventative services that are paid in full. But as, you know, we talked a lot about Medicare, but I'm not aware of any commercial payer that also does not pay for these. I mean, it's, this is absolutely not Medicare specific. Medicare is the one that has a tendency to produce the most information. But yes, it would be subject to the typical co-pays. Yeah, I think one thing too on that is that's all about how you introduce this to your patients and how your patients are educated. Because I do find sometimes it might be one or two patients that may have a complaint, and it kind of shuts it down. And it's like, you know, one or two out of thousands of patients. I think you have to put that in perspective and really consider how you're educating your patients on that up front. I would agree. One thing, this is one I think that's important to talk about. Would it be beneficial to build chronic care management or care management for our nurse practitioners rather than E&M codes when dealing with diabetes, heart failure, etc.? Well, I think we've seen it a couple of different ways. So your advanced practitioners, if your clinical staff can provide the time, what I consider is, are your nurse practitioners working to top a licensure? Because they're billing providers. So if they're doing chronic care management and doing the clinical management time, as opposed to treating and seeing patients in the clinic and billing face-to-face E&M visits at the top of their licensure, I don't know. I don't think chronic care is the right time for them to spend unless it is, I guess, program-driven. What would be your opinion on that, Linda? You know, I guess I can go a couple of different ways about it. I know we have had some people say, gosh, I would love to just be a home-based provider. Okay. So could you help support that APP working from home in rendering virtual visits and chronic care? Well, now that's going to put you into the chronic care clinician codes. So I think there's a case to be made for it. And it might be a component if we have someone that we're trying to, you know, keep that person by letting them work at home three to four days a week on things that could be scheduled virtual. You know, that would be open to an NP that's not open to the nurse. So, but I agree with you. We need to keep them working at top of license. And this is something that, you know, let's hire a phone nurse who does nothing but schedule these calls. You know, what's the ROI on that? Well, do you have the patient population to support it? Are you already doing it, spreading it out amongst multiple people and one person could consolidate? You know, I think that's the direction that we need to be thinking. And, and as you go back and have these conversations with your leaders, you know, certainly reach out to Nicole or anyone on the revenue cycle team, if you need them to join in one of those conversations, you know, that's certainly an option. Yes, definitely. So a couple about RPM, if RPM, who is the digital scale heart monitoring blood pressure, do they get the devices? How do they get the devices? Are they provided by the clinic? I will tell you some vendors provide these as third party services, and they can be purchased as well by the clinic. The key is, are they the FDA approved devices? And are they capable of transmitting electronically? So it's not just a scale that you buy. It's one that transmits electronically via either a software or an app, for example. And those are usually by a third party vendor. There's some out there you can purchase as well. Yeah, there's one here asking about the non face to face and the patient consent. How do we go about obtaining consent for those services? If the referral comes from an outside office, does the consent need to be documented in the chart? I think that's a great question. These will, chances are, at least 90% are going to come from an outside office. And one of the things that we found is just, you know, we did have the occasion to do a couple of different things. You can, if you know that they're coming from a particular ophthalmology group, add a box on their consent form that says patient was advised of the need for consult may result in a, in a visit or a nominal charge. And you can do something like that and or notifying the patient. Just want to let you know, we have your pre-op consent from your GI. Dr. So-and-so is going to look at your chart. We may be able to do this without having you come in. If so, there is a small charge for that, but we may not have to have you come in. And we just got lots of great. That would be nice. You know, they, if they, if you're saving the patient a visit when that's an option. So, yes, it can be a verbal consent, but it does need to be documented if that's your organizational stance. As we spoke about, I think, Nicole, you've worked with some groups and getting this off the ground that came to the conclusion that they felt like this was already in the general consent. The patient's time when they first come in. Yeah, truly just matters what your, what your general consent is and what your process is from your regulatory compliance. I know someone mentioned that they attempted to use Epic and they didn't find it as functional for care management. What I'll tell you, I've learned about Epic and the Revenue Cycle team. We all work in Epic on a daily basis. I will tell you is, is that everybody's Epic is different. And it all goes by if you purchased certain modules, software, all of those things. So I don't know if I can speak to the specific module or anything, but I do know that there's a lot of difference in your systems. So if it's not working for you with Epic, I'd recommend seeing if they have something else out there or what's not working with you. And then also remember our listserv. If you want to connect with anyone who may be doing it and utilizing the Epic, please utilize the listserv. And we also have an Epic specific listserv. We can put that on as well. We use both PCM and RPM in our organization. Is it permitted to have the patient enrolled in both and can have the codes drop on the same day and same month? It is permitted that you can have PCM and RPM built at the same time during the same month. You can't double count time. So you count RPM time, you count CCM time. What I will tell you is I don't know if folks have experienced denials on same day or same month. What I would say is it can be performed within the same month. I don't know if you're dropping the codes on the same day, if there's any type of edit or anything. Linda, have you seen anything about that? I have not heard that that was an issue. Only I would agree with what you've said that the guidelines say they can be built together. But as always, you need to have the documentation that supports each of those individual services and not double count that time. I was looking at the question about 99441 through 443 and I don't have it memorized. Maybe somebody behind the scenes can tell me. Are those the ones that we use now? 441 and 443 is audio only codes. Those are deleted in CPT. Exactly. That's what I wanted to point out. Those aren't available anymore. Then I will tell you CMS specifically, I don't know about these 99446 to 449. Not sure what that is. But I will tell you what CMS has said is that they are going to require for audio that they would be following up with additional information in the final from the final rule and more than likely would be a modifier that's required for audio. So I don't think we have that answer, which hence why we're not using it. I would agree. I think we really need to minimize it. And I can't help but wonder that, you know, if we do get the extension voted through, you know, did Medicare's comments in the final rule when they said they were not going to be able to do it. you know, confusion in the month of January. And I can tell you, we tried to reach out to our big payers, you know, the Anthems, the Aetnas, the United and Cygnus and say, Are you going to accept these new codes? And they're like, what new codes? And they're like, these new codes? Oh, well, I don't know. I think we're, we're also probably in that space of it may just need almost a month of January for the for the dust to settle. And who's going to have us keep billing virtual the same way we do now? Who wants those codes? Who doesn't want those codes? I think we can just anticipate confusion for a bit. Yeah. One question about does the provider need to sign off on the 99457 encounter for RPM, any professional service that requires physician time or provider time and has work RVUs assigned? I will tell you, I would strongly suggest that the physicians are signing off on and reviewing that data, because they are providing that general oversight of the program, and also guidance and management on their care. I think that's about it. I just a couple, Linda and I can answer offline. I'm not sure we know. Are we still required to use 95 for certain payer? Who knows? Don't know if we can answer that for telephone visits. We don't even know who's going to cover telephone visits or how they'll be billed and done. Is the audio only CMS code 98016 correct? No, that is for the virtual brief assessment that replaced the G code. That's not an audio only code per se. It has different requirements than time space. It's called a brief check in code. And they did comment that that is the only one they will cover in 25 is what they said in the final rule. But there again, as we just discussed, I think until the dust settles, we'll just all need to hang out a bit. All right. Well, with that, we will close it out. We appreciate everyone's attendance for our boot camps this week. Appreciate, Linda, all the RCS team who joined us for the sessions. We hope that you found this content valuable as we go into the new year. We're going to be looking at podcasts and other ways to continue to provide ongoing education through our academy platform. We appreciate all of the support. And please, as you hear things from your carriers and those things, share them on the listserv so we can all learn from each other and what's happening in your areas. Well, you know, and I agree. Yeah, I just want to thank everyone. And I'm kind of excited by I feel like we had a few light bulbs go off today, Nicole. I would love to hear from some of you, you know, shoot Nicole on email or myself or Jolene or anyone, Jamie. Send us an email if it's like, hey, thanks for covering that. We are adding this in my practice. We're doing this in my practice. We would love to hear that. Absolutely. And enjoy the holidays for sure. Thank you.

non-face-to-face coding

cardiology

documentation

social determinants of health

caregiver training

chronic care management

remote patient monitoring

RPM protocols

coding and reimbursement

patient care improvements

revenue capture