Hi, everyone, and welcome to our webcast today. My name is Nicole Knight, and I'm the Senior Vice President of Revenue Cycle Solutions and Consulting. It's great to see many of the familiar folks logging into the system. I'm joined by Jamie Quimby, who is a Senior Coding Consultant with us as well. And we're going to be going over an overview of the AMA evaluation and management changes, a real high-level overview, because we wanted to dive in a little more, but we are going to cover those today, and also some key proposed rule impacts. So we're going to cover just a couple of housekeeping things. So now, as you all know, we have a new platform for our education platform, and it is just like Zoom, or it is Zoom. So you can type questions in the Q&A section, and in the chat box, this is used only to have access to the presentation slides there. So if you have questions, please type them into the question and answer section. We will either answer those live, or we will answer them after the webinar, just as we've done previously, as we get into the session and have access to those questions post-webinar, sending that out with the recording. All right. So for coding CEU certificates, just a reminder, for AAPC CEU certificates, you are able to view and download in the transcript section of the Medaxium Academy account. AAPC, as we've mentioned before, has been doing audits on their CEU vendors, and it's very important to understand that our webinars are approved as live webinars. So each individual has to register in order to receive a certificate, and that is a requirement of the AAPC. They have the same requirement. We're not allowed to send handouts prior to the session. We are looking at some options for having some on-demand aspects of potentially getting CEUs, but we are working through that process and evaluating how that will work with our webcast. So please just remember, you do have to register individually in order to receive your CEU certificates or to have them available, and they're under that transcript section. And the good news is that when you have to turn all these in, they will be there for you to go and just download all of them. So you won't have to email and track them down and save them and those types of things. Also, if you do require BMSC certificates, you do still email Jolene for those, and she will send those directly. We have just a couple of folks who require those. So we are going to get started. I'm going to kick us off and go through the proposed rules and a couple of things around the evaluation and management E&M guidelines, and then we're going to get into some questions and answers. So this is the proposed Medicare physician fee schedule, and we're going to cover the key cardiovascular impacts and what are we going to see potentially when the final rule comes out. So you will see that I did underline proposed because it's very important that we remember that this is the proposed rule that's proposed to go in effect January 1st, but they will release the final rule in November, generally. So the financial impacts to our organization. So the conversion factor for next year is set to be decreased by about $1.53 from 22 this year. What does this mean for cardiology? This means that CMS is estimating, and it really depends on your cardiovascular program, the specialty of your physicians, and the mix of services they provide, but the estimate is that cardiologists would see about a 1% decrease in their payments based on either updates to the work, the practice, the expense, or the malpractice RBUs. So we do have the ACC has put together their advocacy, put together a calculator that does estimate what that impact would be based on the proposed rule. If you have not gotten that, it is available on our website. It's also been posted in several of the MedAxium daily news as well, but you can download that spreadsheet and you can see some of the impact to individual CPT codes and those either work RBUs, practice, or that malpractice expense RBUs. Also in regards to the evaluation and management services, Medicare is proposing to adopt the other, what AMA has deemed the other E&M services that they have posted to be implemented on January 1st, and with this, prolonged services similar to what was adopted in 21 for our office and outpatient services. So for many of us, I think that's some good news. Some of it's good news. I think, you know, be careful what you ask for, but it does simplify from a coder perspective and an auditor perspective, what that looks like and not having to worry about for hospital services, we're doing this, for office outpatient, we're doing this, outpatient can be hospital. So all those things, hopefully this will align our evaluation and management services and help us from a coding auditing perspective and also in educating our providers. We're going to start off with some good news, and I think this is good news overall that's proposed and I think we're going to see this be in the final rule. Our split shared services with our nurse practitioners, PAs that we refer to as APPs, APCs, or NPPs, this impacted us this year in that you had to, in order to qualify for split shared services, you had to meet the definition of a substantial portion, either based on time or performing the elements, an element of the evaluation and management service in its entirety. And the proposal was for 23, that that would go to time only. And it has been in the proposed rule that they're going to kick that can down the road till 24, and you will be able to utilize what we are currently doing this year around either that definition of the substantial portion as more than half of the time, or it can be the clinicians having a choice to do one of the components of the E&M service in its entirety, the history, physical exam, or the medical decision making. So what we changed this year in our education efforts, and I know that's been very challenging in how our peer teams are set up, but really not having to go totally to time potentially for 23, which we think it'll stick, is definitely a relief when you look at how our care teams work in the hospital and how we utilize our APPs in cardiovascular. For evaluation and management visits, it's intended, you know, they've been focused on the intent of revamping our E&M visit guidelines from an AMA CPT perspective and CMS. It's been to reduce that administrative burden. They've approved revising what they consider other E&M visits, effective January 1st, 23. And this other category includes majority of our hospital services, observation, several other categories that Jamie will cover in a little bit. The goal, of course, is to adopt the most of the changes that occurred with our office and outpatient services and including, like I said, those hospital observation, home or residence, and a few of the other categories. There's a revision to the coding and documentation framework, so meaning that there's some definition changes, guideline changes. There's also just simple wording changes that they even had in 22 that they've posted in the new update for January 23, and that may have caused a little confusion, and we'll touch on a couple of those that we've been getting questions about and how that's impacting some of our teams. From a Medicare physician fee schedule perspective, the proposed work RVUs, so this is work RVUs only, for those evaluation and management codes, so they're doing away with some of the observation codes. Now, some of them, not all of them, the ones that are same day, those things that Jamie and I are going to go over, but I wanted to just give a snapshot of what the work RVUs look like now that they are consolidating, and it also shows, and it was interesting when you look at for the proposal, it shows that for our H&P initial hospital visits, we see they changed it to inpatient or observation care per day for that E&M service, and it goes to time and medical decision making, but you'll see that for those initial visits, the work RVUs that are proposed actually went down a bit from a national level, and then for our subsequent visits, they went up a little as proposed, or in our discharge services, they went up a bit, so again, proposed RVU changes, we'll know for sure in November, but just to give you an idea, if you do bill a lot of observation services, and those categories impact your group, thinking about what that financial impact will be and what the difference is, thought this would be good just to see a snapshot of what they're doing in this regard. From a telehealth perspective, they're going to maintain elements of telehealth flexibilities that were authorized during the public health emergency, which we knew that many of those flexibilities will continue, and that's great news for our organizations and how we will be able to use telehealth to support our patients. They're proposing to extend it 151 days after the expiration of the PHE, so they want to maintain some of the telehealth codes that are in place that are part of that category three codes through 23 to gather more data for future permanent status, and then they're going to extend 151 days once the end of the PHE happens, where they're proposing to remove many of the services, including those audio-only services and several other of those things, so I think it's important to note that they're still evaluating what are the things they want to continue to offer us that flexibility for virtual care, which is good news, how that's going to affect our practices and programs, and what that looks like from our claims process. The one thing, just a couple of callouts from the proposed rule, for that proposed 151 days after the PHE concludes, they will require the appropriate place of service indicator rather than the 95 modifier, so just some little things like that that are in the proposed rule that'll be interesting to see both as the final rule comes out, as the PHE ends, how that will be impacting our workflows and what we need to pay attention to, and of course this is Medicare, but however, this will apply to our commercial plans, especially our Advantage plans, and they sometimes develop their own rules around those modifiers, so continuing to pay attention. I know most of our organizations have shared that they have spreadsheets and things like that that they're continuing to update and someone has to really spend their time doing, so I think that's going to be important, obviously, for us to continue to do for a bit now of what's being covered under the telehealth approved list. There's a link at the end of the presentation in the resource section that takes you to the CMS approved telehealth codes and how they can be performed and all of those things and when they're temporary versus permanent and all of that, so that is available to you at the end of the presentation. One other thing, there is a provision in the proposed rule around direct supervision through virtual presence. This is something that we really adapted in cardiovascular for our rehab programs, so they are seeking additional information on whether that flexibility should be made permanent, so as you know, in cardiac rehab, therapy, mental health, several things, they've allowed that virtual presence and the direct supervision requirements in individual codes to be done through virtual, and there's definitions around virtual, whether it's audio and visual and audio only, those types of things, depending on your category of codes, but this really helped with our cardiac rehab programs in being able to have a virtual presence for this during the pandemic, and it's great that they mentioned they're going to continue to look at data and we'll see if that flexibility and what the final rule says around that. One of the big areas, there are some proposed cuts to EP ablations, so I know this is going to be a frustration point for our EP services across many organizations. The proposed rule intends to further reduce reimbursement of our ablation services. Also they had reduced the additional ablation codes, both for the pulmonary vein isolation or additional arrhythmias, this year in 22, and they're just proposing that they're going to continue at that same work RVU for next year and not make any adjustments. There's been lots of advocacy around this particular topic by many organizations. I did include the link here because if your EP physicians are hearing about this, they can go to this link and they can reach out and also contact CMS to really provide comments and what they have, they even have language in there of what the organizations have come together and looked at in this space that they can send a message and also be able to provide those comments, and it's very important. One thing, we sit and see that they're making cuts, but we also have to do our part and really contact CMS to oppose those and having your physicians do that through the ACC, not only in EP, but there's some other areas on there that we'll touch on, will definitely be a big help to cardiovascular services, EP services, and important as part of the advocacy efforts that continue in that space. Just to give you an idea of what's in the proposed rule, the work RVU, if you look at our SVT ablations would go down from 22 from 14.7 to 13.8, VT from 19.75 to 16.9, and this one was the biggest surprise, our AFib pulmonary vein isolation goes from 19.77 to 15.8, and I know we have several programs that are still doing very complex PBI ablations and take an extended amount of time, so this was a result of the surveys of the continued data collections from claims and just input across the board, but really seeing that they're taking another hit that's proposed for next year is definitely something that's going to impact our EP services, so just something to note and have your programs please reach out to support. Another area, just from a procedure perspective, they are proposing to undercut some work RVUs that were recommended around new pulmonary artery revascularization services, also pulmonary angiography injection services, and existing pulmonary angiography injection services that are done with our caths. This is primarily used in our pediatric populations for congenital heart disease, so this does not account for that increased intensity and the work of these services, so this is another area that the ACC advocacy has available for physicians to provide content on as well. A few other key takeaways for the global surgery package. This one's been going around and around. They are continuing to solicit comment to evaluate and pay accurately for global service. It seems CMS still believes that there is strong evidence that suggests that the RVUs are inaccurate. They don't say if it's inaccurate in a higher or a lower perspective, but another area where they continue to look at this, so important as you look at your global surgery package and how you report global services, being able to, because this is evaluated from claims data, so want to be sure that you're looking at that, and if you have services you're providing that have that global surgery package, that you're definitely looking at that within your organization. For the appropriate use criteria, it's interesting they didn't in the proposed rules, there wasn't any separate rulemaking that was put in there about appropriate use criteria and the penalty phase or anything. They posted it on their AUC program page, and that penalty phase of the program will now not begin on the 1st in 23, even if the pandemic ends in 22. No timeline is offered for when implementation may begin. I kind of feel like with this one, we have groups that have invested and done some things in this, and there's definitely some overall downstream improvement that that's helped with, but if we keep kicking the can down the road on this one, I think we're all losing interest quickly, so it's very hard to talk about that appropriate use criteria when the can is getting kicked down the road. No timeline offered on this one, but just know that penalty phase is not going to happen next year, even if the pandemic ends. For our quality payment program, there are several details around the QPP program that are proposed, several updates. It includes a timeline for implementation of a new voluntary MIPS value pathway. I encourage you, if QPP has been on the back burner for you through the pandemic and everything that we've been prioritizing, that you do go and look at those proposals and pay attention in the final rule. We'll also be covering that at a session at our fall meeting, and that will be recorded for our CV administrators and physicians and other leadership that attend, our CVSL leaders that attend our MedAxium fall meeting. We will have that available as well for others to listen to. This is not in the Medicare physician fee schedule proposals, but I wanted to call this out because I think it's important, as we can see with AUC and them posting something on their AUC program page, you also, if you are not signed up to receive the MedLearn articles and what's been changed from a CMS perspective on the national CMS website, I know many of you may be signed up on your local, which is also good. It does usually come out on the national first, but if you're not signed up for several of these areas to receive notification when they update the guides that they have available for outreach and education, you want to pay attention to those emails that come in. I know we all get tons of emails, but interesting enough, in May of this year, they did update and change a few things to the teaching physicians intern guidelines. Most of this was around the pandemic and also around when the E&M services for outpatient and office went to time or medical decision making and then really focused around what that means and how the time should be reported. It is clarified. We often get asked about time and the new E&M guidelines, but they did update this. The link is here for you, but this is just touching on those things that changed and really focused on the pandemic services and the office outpatient E&M services. As we get into the E&M guidelines, AMA has published a booklet. I'm sure most of you on the line that are from the coding world have looked at this and have perused it for sure and what that's going to mean for 23. Like I said, we'll cover this more as we get to the end of the year, but wanted to definitely go through at a high level what's there and what's in the proposed rule as well. A couple of things we've been getting questions about because I think this is one thing that is important. The CMS definition of a new patient is an individual who did not receive any professional services from a physician or non-physician practitioner, which is our APPs, our nurse practitioners, PAs, or another physician of the same specialty who belongs to the same group within the previous three years. CMS, they even have the same definition in their guide that they updated from January of 22. It's the same definition from a national CMS perspective. I know that we've gotten some feedback that some of the wording on some of the local Medicare carriers may have changed this definition in 22, but I wanted to point out what the difference was. If you look at AMA guideline for 2023, they also reference new patient versus established patients in that document that they published. If you look in your CPT book from 22, you will see that same information in there. What they did in the guide that they published for 23 is they highlighted a couple of areas. We wanted to make sure we covered this. One thing that they highlight is that this is solely for the purposes of distinguishing between new and established patients for face-to-face services rendered by physicians and what they say the qualified healthcare professionals, which are our APPs, who report E&M services. For new patients, what you will see highlighted, and if you look in your 22 book as well, is they reference the same thing from the CMS definition. New patient is one who has not received any professional services of the exact same specialty. Then they added, unlike the CMS definition on the national and in the E&M guide that they published, it does not have subspecialty who belongs to the same group practice within the past three years. As coders, when you read that at first, and I think, like I said, it's in there this year, but when you read that, you're like, why are they highlighting this? Are they telling me now that if a subspecialty provider within my group practice saw them in the same specialty, they're not able to bill them as a new patient? Well, we're going to talk about that and what that means. It's not a change. Same thing on the established patient. They have that same classification around subspecialty. That was added in 22. If you look at the AMA guide for 23, you will see that they refer to the decision tree for new versus established patients to aid in determining whether you should report a new or an established encounter. Now this is not a payer specific decision tree. This is an AMA CPT tree. So your commercial payers, your advantage plans, your local Medicare, all of those, many have adopted what AMA CPT has, but this decision tree is not in that 23 guide, but it is published in this year's CPT book in 22. And it's always been there. I just don't think it's something we've necessarily utilized or definitely pointed to. But this, when you look at it and you look at those definitions and you begin questioning on how you're billing, especially for your subspecialty services, which are EP, Advanced Heart Failure Transplant, if you have interventionalists, those types of things, and you follow this decision tree from CPT. So it says, has the patient received any professional services, E&M, other face-to-face service from a provider or another provider, which is our, you know, we refer to as our APPs, same exact specialty and subspecialty in the same group practice within the previous years. So if you have a patient who saw your invasive cardiologist and they're referred to EP. So you ask yourself this question, have they received professional services from the provider or another provider in the same exact specialty or subspecialty? Well, if they're going to the EP and they have not seen an EP physician in the group, that's one thing we need to know. So if someone in EP has already seen them, they're the same subspecialty. But if you look at this, are they the same specialty? Obviously, if they're not the same specialty or subspecialty, we know it's a new patient. If we're the same specialty and we're all cardiologists, however, they have not seen a provider in the same subspecialty, then they are a new patient. If they have seen a provider in the same group, in the same subspecialty, it takes you down to no, it's a new patient. So if your interventionalist refers a patient to an EP physician within your same group, and that patient has not received a professional service from an EP physician in your same group, it still directs you to yes, it can be billed as a new patient, or I'm sorry, no, it can be billed as a new patient if they're not the same subspecialty. So there's no difference in this. It's just a matter of the wording and that gets very confusing. So if we say, yes, our providers are in the same group, they're all cardiologists, but are the providers the same subspecialty? If it's no, it's a new patient. If it's yes, it's an established patient, meaning they saw any subspecialty provider who's designated as EP or that particular subspecialty. So look in your CPT book because it's not something I think any of us, there's a lot of these in there, but the AMA guidelines do point you to a decision tree. And there are several decision trees out there because I know AAPC has published one and it has some variables of this. I know that some of the local Medicare carriers have published some that are variables of what's in your CPT book, but you wanna pay attention to what this decision tree is being referred to for your services in that 23 guideline and looking at the guidelines for this. So that was a little confusing. We've been getting a lot of questions about, we can't bill a new patient for an EP physician anymore. Is that what this means? Again, you have to go down that decision tree. Not all your payers are gonna recognize it. Not all your local Medicare carriers may follow that guidance either. So it's very important to understand what goes on in your payer environment and what they're following from that perspective. But this is what's in the AMA CPT book. All right. So I think I covered most of these points. So the AMA refers to the decision tree for new versus established patient in the guide that's published under other E&M services. Unsure of the variable, the CMS definition versus the AMA definition. Currently the CMS definition doesn't have that term subspecialty in the definition, but they adopted the AMA current CPT definition. And in the proposed rule for this for 23, they even say we will adopt the revised CPT E&M guidelines for other E&M services, just as we adopted those for office and outpatient E&M services. So it tells us they're going to, from a national perspective, even in the proposed rule, we're going to adopt what's being proposed by the AMA CPT. But as we know, different payers have different guidelines and they adopt things in many different ways. And there's no way that we can cover or know all of those different ways from all of the states across the country. So it's very important for your local region that you understand what's happening with your payers, your advantage plans, your local Medicare carrier. Another thing that's in the 23 AMA publication of our other E&M services, they clarify, and I thought this was interesting because we're often asked this question. In the instance where a physician or APP is on call for a covering for another physician or APP, the patient's encounter will be classified as it would have been by the physician or the APP who is not available. So when we talk about call and call coverage, so if you have an EP that takes general call, that's just like providing call coverage for his partners on call that weekend and being billed the same way it would be billed if that partner was covering. Also, when an advanced practice nurse and physician assistant are working with physicians, they call out that they are considered as working in the exact same specialty and subspecialty as the physician. Remember, this is an AMA CPT definition. When you look at the proposed rule, it refers to, this is one comment that's in there, and we all know this is like 2000 pages of information, but this comment is in there where they do refer to from a Medicare perspective in the claim processing manual around the longstanding taxonomy codes for physician services will continue to apply. Well, for payment purposes, physicians and non-physician practitioners are not classified as having the same specialty and they do not recognize subspecialization for APPs, and they're gonna continue to evaluate that from a CMS perspective. So as you can see with the subspecialization of cardiovascular services, both for our physicians and our APPs, they're continuing to look at that for APPs. But if your APPs are working in EP, then they're considered as being an extension of that physician and working as an EP APP, but they're not classified from a CMS perspective as being subspecialized. So if that APP has seen the patient before, that's where we go back to those definitions and looking at those decision trees. So Jamie is going to take over now and is going to dive into the overview of the other E&M services. Jamie. Hello, just swapped over screens. Is everybody seeing everything okay? Yes, Jamie. Okay, perfect. All right, well, thank you so much, Nicole. Hello, everyone. I'm gonna now cover with you some of the more specific 2023 updates that were released from the American Medical Association for those hospital evaluation and management services and some of the other categories. We have been expecting these much needed changes from the AMA and we are happy that they, along with CMS are revising these services to help simplify it more for the practitioners and for us that live in the coding world. So I'm gonna give a brief overview of these updates and we're gonna cover in great depth during our December bootcamp series. Once we have that final rule released and we combine that with what we know with the AMA, we will definitely be giving a session during that December bootcamp series where we'll definitely dive in more depth with this. So from AMA updates, what we know is there will be updates to the time assignments for each service, which we know we received that back in 2021 with the office outpatient. We also know that there's gonna be revised guidelines for the hospital and other E&M services. We know that in choosing the level of service, it's all gonna apply now to either that medical decision-making or time-based, which minus a few areas of the E&M categories that time is not allowed to be considered. So for example, our emergency department visits, there is no time assignment for those services. So we'll cover that in a little bit more detail in an upcoming slide. They did align the guidance again for the hospital and other E&M categories to eliminate the use of the history and exam only in calculating your level of service. So again, these will still need to be documented as medically appropriate, but we no longer have to do all the scoring when selecting the overall level. So that is a good change. As an auditor, I always felt really bad when I had to ding a service I was auditing because I saw family history was missing, or I saw that famous word that we know most of our carriers don't accept with them saying family history non-contributory. So again, this is a good change that was needed. So we're just factoring in that medical decision-making or time-based if it is allowed for that service. So these are the deletions that we know will happen in 2023. We know that with the consultation services for our outpatient and inpatient, that the level ones are gonna be deleted like with what we saw with the 99201 being deleted with the 21 updates. So that 99241 and 51 will be deleted come 2023. Hospital observation services will all be deleted and they're going to align the descriptors for the initial and subsequent visits for our inpatient services to also include the observation services. Now, same thing with the discharge. So that 99217 for observation discharge will be deleted. And then they're going to revise that the 99238 and the 99239 for our inpatient discharge to also include the observation discharge services. There's gonna be some deletions of prolonged services but they're gonna be revising some of the existing services. And we do know that there will be an addition of a new prolonged service code. So we'll cover that in detail in an upcoming slide. We don't typically live too much in the last three areas here in cardiology. We can occasionally go to these facilities though. So we'll touch up briefly on some of the nursing facility changes and the home or resident changes. So revision guidelines there, if you opened up the AMA booklet that was released for 2023, you'll see there were a lot of items marked in green throughout that PDF file. So a lot of the guidelines for the categories were revised by the AMA. We'll go through some specifically as we go through today's presentation. So just keep that in mind. If you're looking at the AMA booklet, you're gonna see a lot of green initially. Some of that was to also include the hospital and other E&M categories now. So let's start with the area we see the most common in our cardiology world for the hospital E&M services, this initial and subsequent visits. These historically have had separate codes to choose from depending on whether the patient was inpatient or observation. This does of course include the discharge codes that are available to report. The AMA did wanna simplify this and combined everything, which is why they decided to delete those existing observation codes that are currently available and revise the other existing services to now include inpatient and observation status. They're further adding clarity on the initial and subsequent definitions with this update. So with the initial visit, the patient has not received any professional services from the physician or qualified healthcare professional or another physician or QHP of the exact same specialty and subspecialty who belongs to the same group practice during that inpatient observation or nursing facility admission and stay. So that's gonna be the big key difference with whether you're gonna choose that initial or subsequent. Is this a brand new admission for this patient or have they been admitted? Maybe you signed off for a little bit and you're being called back in to see the patient during that same admission still. So that's gonna determine whether you're gonna build that initial or that subsequent. So these are the codes, not much change with that. The 99221 through the 99223, these are all familiar with us based on the inpatient status, but the key here again to note for 2023 that this will also now include observation care. So this will be inpatient or observation care for that admission. So with the 99221, oh, you're also gonna notice that the time allotments will be updated for 2023 compared to what you currently see in your CPT book for 2022. So for the 99221 for 2022, for example, the time assignment currently is 30 minutes. So for 2023, they're going to update it to 40 minutes. That must at least be met or exceed in that time threshold. So for that 99222, the current assignment is 50 minutes. So that's gonna be increased by an additional five minutes. And then same thing with our 99223, it's currently assigned 70 minutes and that will be increased with an additional five minutes to up to 75 minutes. So per the 2023 AMA guidance, when time is used for reporting that E&M service, the time defined in the service descriptors is used for selecting the appropriate level. The E&M service for which these guidelines apply do require a face-to-face encounter with the physician or other qualified healthcare professional and the patient or the family or caregiver. So for coding purposes, time for these services is the total time of the date of the encounter. So that's in line with what we know with the 2021 updates. So it's time based on the date of the service provided to the patient. So you can't spend any time reviewing anything prior to the visit on another day or after and include that time with this one service on this date. So just keep that in mind. Again, that note has to support that face-to-face did occur during that same date. Again, if the service exceeds the time threshold, there is going to be a newly created prolonged service that will apply to our initial hospital inpatient or observation care services. So right now you see that there is a placeholder code. So we do know that there will be a new code created for 2023. We just don't have it specifically yet. So we'll cover again all the prolonged services in an upcoming slide, but just keep in mind that currently it's saying for services of 90 minutes or longer, you would use that additional prolonged service code with those. So these are our subsequent. Again, not much change there except for the descriptor also now including the inpatient or observation care. The time thresholds here will also be updated for 2023. Some are a little bit significant. So for the 99231, that currently has a time assignment for this year of 15 minutes. So you can see that's gonna be bumped by an additional 10 minutes. The 99232, which is kind of our most common is gonna be bumped by 10 minutes also. So it's currently 25 minutes and it will have to be at least 35 minutes now. And then the 99223 is currently assigned the 35 minute threshold. So that will be increased to 50 minutes. So those are a little bit of a big change I would say compared to how we report those services now based on time. So again, you have to meet that threshold. It has to meet or exceed. If it exceeds, then if you're going to be looking at those prolonged services, again, you're gonna have to make sure you at least hit that 65 minutes or longer to support that additional service. These are for our admission and discharges same day. We don't see these two common in cardiology. It can happen occasionally though. So what the AMA is stating here is these do require two or more encounters on the same date of which one of the encounters is an initial admission encounter and the other would be a discharge encounter. So the AMA is saying if the patient is admitted and discharged at the same encounter, then they are instructing you to only report the initial visit with that 99221 through the 99223 service. So if you're looking at reporting these, just keep in mind, you're gonna have to have two separate notes. You're gonna have that initial admission note and you're gonna have to have a separate discharge summary in order to bill these services. Again, for prolonged services, you're gonna have to at least meet over 100 minutes or longer to add that additional code that will be created come 2023. So for discharge, remember the 99217 for observation we know is going to be deleted. So they are just going to be updating the description of the inpatient hospital discharges to include observation care also. These are time-based services. So again, you're gonna need the time documented in the note to make sure you're picking the appropriate code. So that's the big change here. Again, they're gonna just be adding that descriptor and it'll include inpatient and observation. Consultation. So we know for many years now, Medicare stopped accepting these services. There are still some carriers out there that do want these reported though. And I can tell you, depending on your state, it's going to vary. I know some states Medicaid programs still want consults reported. Other carriers don't want them reported at all. They want you to report either that initial visit or subsequent, whichever's more appropriate based on the patient's admission status or where you're seeing them, whether it's in the office setting or hospital. So just keep in mind, it might be a good thought to contact some of your big payers at the start of the year and see if they have any updated guidance on these consult services and whether or not they're gonna accept them or not. So what we do know is that they will be deleting the level one consult services like they did with the level one new patient office visits that 99201 that got deleted. So they are gonna be deleting the 99241 and the 99251 for 2023. And this is because of us moving to that medical decision-making or time-based. There was no need to have a straightforward medical decision-making for two levels of service. So that will be the big change there. So the AMA does do some updates with how they define a consult service. So if you look in that AMA guide, you're gonna see all that marked in green. So some of the stuff they highlight is a definition. So they say it's a type of evaluation management service provided at the request of another physician or qualified healthcare professional or appropriate source to recommend care for a specific condition or problem. So the consult is initiated. If it's initiated by a patient or family and not requested by a physician, qualified healthcare professional or other appropriate source, then you cannot report the consult service codes. You would report the other appropriate E&M category depending on where you're seeing your patient at. So say it's a office visit, you would just report a new or established patient depending on if that patient's established with the practice or not. So you would not report a consult code if it was initiated from a patient or family member. The consult service descriptions will also be revised again for 2023. So that 99242 through 99245 will include office or other outpatient service. The 99252 through 99255 is now gonna include inpatient or observation consult service. So that's another big update there. They're kind of trying to keep in line with the inpatient observation statuses and keeping those grouped together. Again, though, you're gonna wanna check with your payers specifically on whether they even allow reporting on these services or not. So of course, if they don't allow for it like Medicare, you would just default to the appropriate category. So these are some of the following codes that are to be used for consults when they're provided in that office or other outpatient sites. So this would include, for example, a home or residence or maybe the emergency department. So this is where you can report these services if your carrier accepts. So follow-up visits in the consultant's office or other outpatient facility that are initiated by that consultant or patient would be reported with the appropriate established patient office codes at 99202 through the 99215. Or if it's done in their home or residence, it would fall within the 99347 through that 99350. Services that constitute transfer of care are reported with the appropriate new or established patient codes for that office or other outpatient visits as well. Just again, keep in mind that 99241 will be deleted. And then they are also going to be updating the time assignment from 2022, current time that you'll see in your book. So that will change come 2023 with the different time assignments that you see here. Again, if you are looking at prolonged services, reporting time-based, you would have to hit 70 minutes or longer to use the current 99417 prolonged service code. So these are gonna be for your inpatient or observation consult services. So again, they're gonna be updating that descriptor to include also the observation now. Then that 99251 will be deleted come 2023. They also have that placeholder for that 993X0 for the prolonged code. So we know, again, that's gonna be whatever code they come up with for that prolonged in this inpatient observation category. We'll be receiving a new code there for the prolonged services. Emergency departments. So from an AMA definition perspective, they define an emergency department as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day. So this is defined by the AMA, excuse me. So for critical care services, because we do get this question a lot, what if you see a patient in an emergency department setting but they are critically ill? You can still report your critical care services. It does not matter where they are in the hospital setting. If they meet the definition of critical care, you can still report your critical care services. So the AMA does highlight that in their updated guidance as well. There may also be an occasion where maybe the patient is initially seen in the emergency room as a consult service, say for instance, patient has not yet been admitted. They're still sitting in that emergency department status, but something in their status has changed and the physician is called back in to see the patient based on whatever has changed in them. So now you have two E&M services on the same day. It's gonna be rare, but if you have a scenario, you find yourself in reviewing something like this with your practice, you can report both E&M services. So you would have your appropriate emergency room E&M service depending on your carrier. And then you would be able to report your critical care depending on how critical they were and if they're meeting that definition of critical care. You would have to report an append modifier 25 to the appropriate E&M service to show that there was that separate identifiable service that was provided to the patient on the same date as another service. So rare scenario, but I have seen it happen. So just wanted to point that out. The AMA does highlight that in their booklet that they released. Another thing the AMA does state that if a patient is seen in the emergency department for the convenience of a physician or other qualified healthcare professional, you would not report the emergency department services. You would instead report the appropriate office outpatient service with that 99202 through the 99215. I don't know if I can say I've ever seen anything like this documented from a physician documentation perspective, but the AMA definitely felt the need to add that clarification. So it's possibly something they have seen themselves, but in cardiology, I don't know if I've, again, if I can ever say I've seen a physician recommend the patient to go to the emergency just out of sheer convenience for the physician. So again, just wanted to point that out. If for some reason they're not meeting that definition, you would just report your appropriate outpatient office service. So these are the codes available. Nothing much has changed there. A big thing I wanted to point out here though is time is not a descriptive component for these emergency department levels of service. And this is because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several different patients over an extended period of time. So the AMA does not assign time to these services. So this would be, again, one of those examples where you would have to report based on that medical decision-making as there is no time distinction made with these. So this was an interesting update to the nursing facility for the medical decision-making portion of the selection. We might not see too many nursing facility E&M services in our world. I do know being in a prior practice, there are occasions where cardiologists may be doing rounds at a nursing facility. So definitely can come around where you're reporting these types of services, but I definitely wanted to point this out. So what the AMA updated here is when selecting a level of medical decision-making for nursing facility services, the number and complexity of the problems addressed at the encounter is considered for this determination, a high level medical decision-making type specific to the initial nursing facility care by the principal physician or the other qualified healthcare professional is recognized. What they further clarify is multiple morbidities requiring intensive management, a set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and or re-evaluations. The patient is at significant risk of worsening medically. So what they're saying here is if the patient has multiple conditions that are going to be requiring intensive management at that initial visit, that medical decision-making for this kind of scenario most definitely can fall at a high level just based on this information. So some things to point out with the initial nursing facility care codes, these may be used once per admission per physician or other qualified healthcare professional regardless of the length of stay. So sometimes with our nursing facility patients, they may be in that facility for a very long extended period of time. You could only report that initial service once per that admission. So that was definitely spelled out clearly in the updated guidance. Anything after that would default to your subsequent nursing visits. So just another item to point out there. So these are the codes available. Again, you'll want to pay attention to the time assignments as there's been some updates with those. Again, there's that placeholder for the upcoming newly created prolonged services code. You'll notice a trend with that code that it's applying to any initial facility charge. Some of the codes that they did delete had to, they fell in line with those. So they're going to be deleting those and making this new code. And then again, we'll be covering prolonged in just a few minutes, but they'll be revising some of the other services. Here's our subsequent options for reporting. Again, big thing, again, medical decision-making here or you have your time assignments here. So it's just going to depend whether you're reporting based on that medical decision-making or time and what all is supported in that documentation. Discharge, again, these are also time-based like our hospital inpatient observation services. So you'll definitely want to just make sure the time is supported based on documentation. So again, one thing they highlight in here, the nursing facility discharge management codes are used to report the total duration of time spent by a physician or other qualified healthcare professional for the final nursing facility discharge of the patient. So again, it falls in line with our hospital inpatient observation where the code selection is based on that total time. So home services did get some, or they will be getting some revisions for 2023. So revisions to the home services guidelines to include home or residence. They further define the home may be defined as a private residency, temporary lodging, short-term accommodation. So maybe a hotel, a campground, maybe they're in a dorm rooms, a cruise ship, anything like that where they further define what that short-term accommodation is. So these are codes, these are grouped based on whether it's going to be a new patient or established patient. So with the, you'll notice in this listing here that there is no 99243 code. So it goes from the 41, 42, they skip 43, go to 44 and 45. So they're actually deleting the 99243 for 2023. This was because it had a moderate medical decision-making but that detailed history and exam. Now the 99244 is also moderate medical decision-making but it had that comprehensive history and exam. So again, with aligning with the 2021 guidelines where we're basing based on medical decision-making or time, there was no need to have that 99243 anymore because that was too moderate levels to choose from since that it goes to that medically appropriate history and exam now. So that's why they deleted that 99243. Again, if you are looking at reporting these services just paying attention, is it going to be a new patient with your group or established? If you're looking at the time-based again, you'll have to meet or exceed the allotments that are assigned for 2023. If you're looking for prolong, you're going to have to at least hit 90 minutes or longer to report that 99417. So these are the codes for established patient home or resident CPT reporting. So based on medical decision-making or that time and whether that patient's new or established is how you would determine which category you're going to fall in with these services. All right, prolonged services. So what we know for 2023 is they are going to be deleting the current 99354 and 55, which these were for prolonged services in the outpatient setting that required direct patient contact. They're also going to be deleting the 99356 and 57. So these were prolonged services in the inpatient or observation setting that required direct patient contact. So with the deletion of those two categories there is where they're going to create that new category with the placeholder, the 993X0 right now. So that will become, they'll give a CPT code for 2023 and that will apply to our hospital services once we know what that code will be. They're going to be revising guidelines to the other categories. So we'll cover those in an upcoming slide in just a second. So the 99358 and 59, these are existing prolonged service codes. These are provided on a date other than the date of the face-to-face evaluation and management encounter with the patient or family or caregiver. So codes 99358 and 59 may be reported for those prolonged services in relation to any evaluation management service. Again, on a date other than the face-to-face service provided to the patient. The services to be reported in relation to other physician or other qualified healthcare professional services, including the E&M service at any level on a date other than that face-to-face to which it is related. So key to point out here, can't be on the same day you saw the patient face-to-face and it has to be related to a face-to-face encounter with the patient. So just keep that in mind if you're looking at reporting these services. If it's anything less than 30 minutes, it is not to be reported. And then you can see the time thresholds additionally based on what is supported in the documentation. The other existing categories with the 99415 and 16, these are used for an E&M service that is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time with the patient. So this has to do with clinical staff time that is provided to that patient. It does require direct supervision from a physician or a qualified healthcare professional. So this would, again, the 99415 is used to report that first hour of clinical staff service. And then again, anything additional based on what is supported by that documentation. So the AMA did put together this very helpful chart. So I put it here in the slide for you. So they talk about the typical clinical staff time based on the level of service. Then they give you the time range that must be documented for the 99415. And then the starting point, if you're gonna look at reporting that additional time with the 99416. So definitely found this very helpful. So if you're looking at reporting these services for any additional support that your clinical staff is providing, this table is very helpful to help determine which threshold you're gonna need to meet. Finally, with our code 99417, this is used to report prolonged services that is combined time with and without direct patient contact. It is provided by the physician or other qualified healthcare professional on the date of the office or other outpatient service. So the 99417 does apply specifically to your highest level E&M services for your office outpatient. So that would be your 99205, your 99215, your consult 99245. It lists specifically in the CPT book what you can report the service with. For the upcoming newly created, newly code that will be created with the placeholder, we know that that one's gonna be applied directly to our hospital inpatient observation services. Some of our nursing care services as well, it'll apply to that. So this also has to be additional time on the date of the E&M service to the patient. So it will have to include that face-to-face on the same date. And then we have a helpful table coming up here. So I added a table with the current code that we currently have in that exists. So this is an example of your office outpatient service. So for example, if you're looking at the timetable, so with our consult service with the 99245, we know for 2023, that level five service has a time allotment of 55 minutes that must be met or exceed. So to calculate any additional prolonged service time, you would have to meet or exceed at least 70 to 84 minutes in order to report this service. So again, keep that in mind with that 99417 and that upcoming new code that will be created. You have to hit the highest level threshold in that E&M category if you're gonna be time-based reporting and then report any additional time based on what would be reported by that, supported by that documentation. One item I wanted to point out in the updated guidance is, because we get a lot of questions about this with that MDM component with the data section. So the AMA did further add clarity to this and I'm gonna highlight it in bold here. So they say, the ordering and actual performance and or interpretation of a diagnostic test or study during a patient encounter are not included in determining the levels of E&M service when that professional interpretation of those tests or studies are reported separately by the physician or other qualified healthcare professional that's reporting that E&M service. So we know, for example, the biggest one that we cannot count would be like our office EKGs because the physician is ordering and performing and billing for that interpretation separately. So you would never be able to count that in your office setting if your provider's going to separately be reporting and interpreting that study. So you couldn't count it as far as your data section goes. What they added here is tests that do not require a separate interpretation and are analyzed as part of the medical decision-making do not count as an independent interpretation but may be counted as being ordered or reviewed for that data selection when you're looking at that medical decision-making table. So an example here would be maybe they're reviewing labs. So they're not going to be giving you an independent interpretation of those labs but they are reviewing them so they can recount, they can count what they reviewed as a data point in that section. So it wouldn't give them that independent interpretation but again, you could still get credit for that. This is the 2023 updated table. So I added them individually just to kind of help simplify it and make it easier to read. So for the straightforward, we're not going to have a whole ton in this area. This would be like your 99212 or your 99202 for new patients, for example, for your office. So it would be one self-limiting or minor problem. You would have minimal or no data being analyzed. Your minimal risk of morbidity would be very minimal also. So an example where you might fall here is maybe a patient, established patient that has palpitations. Maybe they had like an extended Holter pit on like a ZO patch. It showed it was normal. Patients coming back in for follow-up, provider basically says follow-up PRN. This is where you would probably fall with the example scenario like that would be a straightforward visit. For low, not much change here. They just added some of the requirement, like the hospital inpatient or observation level of care, you know, where you could fall if it's just an acute uncomplicated illness or injury. Again, you're still going to have to meet the requirements if you're looking at data of at least one out of the two categories. So again, you have category one, category two, and any of your risk for, and any of your risk for, your overall risk would be low for morbidity or additional diagnostic testing. Moderate, again, they just, not much change here as well. You still have to meet, if you're looking at data, you're going to have to meet at least one out of the three categories. So this is where they add additional information, whether or not you discussed management of a test interpretation with another professional. Typically, it's easy for us in cardiology to hit this category one, especially if they're reviewing any prior notes, reviewing any prior test results of, you know, a unique test. So this is where, prior with the 95-97 guidelines, we struggled with this because it fell based on CPT section in the data category. So especially with your hospital encounters, if provider orders an echocardiogram, a carotid duplex, we know those fall in the medicine section so that we would only be able to give them that one point for that. But now, based on the 21 guidelines that were updated, we can give them two points because those are each a unique test. So you would have to meet a combination of at least three bullet, or three items from these four bullets. So if you reviewed, you know, two outside tests, maybe some lab work and a previous echo that was done, and then you're ordering an additional test, like maybe a nuclear study, you'll have hit three just from those three items there. Again, these are examples only when you're looking at the moderate risk category. So this is still kind of a gray area for us that we hope, you know, maybe with CMS aligning with the AMA, they'll update their guidance to, we know with 2021, they referred you to the AMA guidelines. I'm hoping that they at least update that table of risks because it is pretty helpful when you're looking at that overall, but you cannot combine the items together. CPT assistant did release an article after 2021 that specifically states you cannot combine the AMA guidance with the CMS guidance. So maybe we'll get some updated stuff from Medicare with that, that'll align with the CMS, that will have more examples for us. But so for now, what we have is we know that these are examples only. So it is gonna be up to your clinician to determine that overall risk component and where they feel that patient will fall. For high, again, not much changed here. This all stayed the same. It would be one or more chronic illness with severe exacerbation or progression or one acute or chronic illness that would pose a threat to the patient's life or bodily function. For the data category, you would have to meet at least two out of the three categories. So this can be a little bit harder to meet. Typically, like I said, we can easily fall as a combination of the three, but then the provider would have to at least do an independent interpretation of an outside test, or they would have to have a separate discussion of management or a test interpretation with another healthcare professional. Examples that fall in that high risk, we know that drug therapy requiring that intensive monitoring for that toxicity is there, decision not to resuscitate, or if they're deescalating care because of the patient's poor prognosis. So those types of discussions that are documented in the patient chart can help you fall under that high risk category for the risk of complications. All right, well, that takes us to our end. So this is our MedAxian disclaimer. This is stating that this was for informational purposes only and does not constitute legal reimbursement, coding, business, or other advice. You should always check with your local Medicare carrier and your other big payers and consult with your practice's legal counsel for any coding and reimbursement advice. Finally, everything we did cover today was from CPT disclaimer. All the content that we covered in detail was from the American Medical Association. These are the helpful resources Nicole had mentioned at the start of the presentation. So if you are wanting to go to the information specifically, we added these links. Again, the AMA guide is very, very detailed, very helpful. CMS also put out, like, a fact sheet for the proposed rule that kind of just highlights some of the big areas that they are proposing for next year. And with that, that brings us to our Q&A. Thanks, Jamie. A couple of things I wanted to comment on from the Q&A that's coming up. So one thing, and we are, you know, continuing to look at how this is going to impact our practices with inpatient observation services being combined or admit codes and observation services being combined. But there's one thing that we have to remember. Place of service does not change. Place of service, based on if that patient's admitted to observation, if they're admitted to inpatient, whatever their place of service is, we will have to get that right on the code from a reimbursement perspective. So CPT, AMA, does not publish place of service. That's a payer guideline. So even though the AMA has published these changes for 2023, our payer guidelines are going to dictate those CPT codes, place of service, and how those are used. So you will still use, based on the place of service, the appropriate section code, but you will be reporting that place of service. The other thing that I wanted to mention, and we did not go over this from the proposed rule because I didn't want to cause levels of confusion. This webcast was truly just to give you a snapshot of what we can expect to see that will be, of what we might be saying is final in November or what's changed. But all of the prolonged services that Jamie went over, typical CMS, so in the final rule, if you look at the context around those prolonged services, they do talk about which ones they would reimburse, which ones they wouldn't. I will tell you the codes Jamie went over that were for some of those non-face-to-face services, things like that. They will tell you like that 99358, 99359, they're proposing that those codes are inactive for Medicare, meaning they're not going to assign a reimbursement potentially to those. We don't know that's a proposal. Also for those CPT codes that the AMA have defined for prolonged services, Medicare is saying they're going to have G codes for those and they don't give us the G codes. It's just GXXXX right now in the proposed rule. So I think it's good to get familiarize yourself with prolonged services, but truly if you're looking at how you're going to communicate these things to your physicians, the things you're going to think about, I would think about, this is really going to be a lot of things that are going to be done on the backend. For prolonged services, I would wait until the final rule, particularly around what Medicare is going to reimburse, what G codes they're going to use versus the CPT codes. Also got to pay attention to the telehealth list if you're trying to provide those services, audio only. So several of those questions have come up. I wish I could tell you all the definitive answers. I think you'll hear more from us. I know you will about that both in November when we talk about the final rule and then also in our bootcamp in December. So I just wanted to add that, Jamie, I don't know if you see anything else, but place of service is not going to change. You still are going to have to know what is that patient's place of service? What were they admitted to? Was it observation? Was it outpatient? Was it inpatient? And then that's going to direct you to your code categories to use. Yeah. Yeah, I don't have anything else. The only other item I just wanted to briefly point out is you'll see that we've started adding general case questions. So as part of membership with MedAxiom, if you do come across, find yourself coming across a difficult case that you're looking at, or you have a physician that ask you for additional clarity on something, you can email this email directly. It'll come to the entire revenue cycle team. And then one of us will be able to grab that in a timely manner to help assist with that question. And other than that, I think that brings us, oh, I'm sorry, that brings us to our end. So we thank everybody for joining us today. And we will have two webcasts next month. So stay tuned. We'll get those registration links posted as soon as they're available. So again, there will be one, I believe at the start of the second week of September possibly, and then I'll be giving a update on the ICD-10-CM guidelines and code changes for 2023, the third week of September. Well, thank you everyone. And we will continue to provide information as all of this unfolds around the E&M guidelines, around the proposed Medicare rule. We'll provide information on our listserv, also through our webcasts that are coming up. And once we get some finalization, if you ask some questions that we did not answer or type in the answer to, or answer verbally on the call, we will send those out when they have the webcast recording posted and you'll get notification of that. So we appreciate everyone's time and we hope you have a great day.

Evaluation and Management guidelines

2023 updates

E&M codes

inpatient care

observation care

subsequent visit codes

discharge codes

coding and documentation framework

medical decision-making

time-based criteria

American Medical Association

payer-specific guidelines