Thank you, Kathy, for that dive into the breaking news. The next few talks that we're going to give or that I'm going to give have to deal with understanding those E&M guidelines. So we're going to talk about this in two parts. I'm going to talk about this as far as part one, complexity of problems addressed and data reviewed and ordered. All right, so again, some of the things that we're going to talk about, really going to focus on the first two components to medical decision making. All right, complexity of problems addressed is kind of that first component to decision making, and we're going to talk about some examples. So the data reviewed, ordered, analyzed, speaking to other providers, those sorts of things. That's kind of the second component to medical decision making. And then we're going to end it with practice pearls. All right, so polling question. I'm going to pick your brain. You've had your cup of coffee. We're picking the brain. All right, does reviewing internal records count towards a data point for medical decision making? Yes? No? I have no clue. Depends on which internal records you're reviewing. All right, yes, is 37. Look at that, 37% for yes or depends on which internal records were reviewed. All right. Hey, at least a couple of you were honest that I have no clue. All right. The answer is no for office visits. All right, so that was one of the changes that were made when we went through, when we kind of learned the updates, learned the E&M guidelines is when they came out with those new guidelines, one of the things that were addressed for data, the data component, the data category is that they have to be external records. So primary care records, hospital records, et cetera. So if it's from an outside source, it does count. Now, that's not to say that your internal ordering of a test or reviewing a test doesn't count. Those do count. And we will dive into that in the second part of my talk. All right, so before we get into those first two columns of medical decision making, I just wanted to kind of bring you back into those major changes that we had to the office E&M guidelines. Okay. So we're going to kind of just do an overview of this before I get into those components. So remember, the next couple of talks, when we're talking about the E&M changes, we're only talking about office visits, okay, 99201 through 205, 99211 through 215. These are the CPT codes that this impacts. Now, they have deleted 99201. That's a new patient level one. I don't think we got offended by that. You're GI. You're a specialist. You're not seeing level one straightforward patients most of the time, okay? So if you try to build that right now, you're going to get a denial back that says this is not a code anymore. There's new guidelines specific to all other outpatient levels of services, 99202 through 215. Scoring for new and established patients, there's changes there, and we're going to go through those in this talk and the next talk. Medical decision making, we're really going to dive in to all of those elements, give you clinical examples, just so you can understand it, and keep in mind, some of these guidelines are still vague. You know, it makes it challenging for those of us that are auditors, that are coders, that are looking at those visits to make sure that you are billing the appropriate level of service. When some of those areas are very gray, guess what? It's up to you, the provider, to document those things, get them in your impression and plan of care, tell us the risk of the patient, et cetera, okay? Because remember, if it's vague, guess who makes the decision? The payer that's looking at your documentation that's paying you for that level of service, okay? There's changes to the time-driven visits as well, because as you guys probably are aware, when you bill by time in the office outpatient setting, you can bill total time of the encounter, okay? But time is not associated with 99211. That's typically our nurse visit, our teaching nurse visit, et cetera, so really not for the providers to assign or to bill. History and physical exam is still required, but will not be part of scoring to determine your decision-making. Your level is chosen by medical decision-making or total time, okay? Keep that in mind. That doesn't mean you don't have to document history and physical. Just to make that very, very, very clear is it needs to relate back to the chief complaint, so we don't have to have a disrotation of history and examination. You do what's pertinent to the chief complaint. Your assessment and plan of care is going to paint your level of service, all right? So we're going to talk about the number and complexity of problems addressed. We're going to talk about the amount of data to be reviewed, analyzed, ordered, et cetera, and then my next talk will be the risks. Bottom line, medical decision-making, medical necessity has to be contained within the documentation. We do have a link provided. That is the link to the AMA, and that gives you all of these guidelines that we're going through. All right, so if you look at this table, this breaks down your levels of services and what you come up with for total decision-making, okay? So your level twos, whether it's new or established, straightforward decision-making, level three is your low, level four is your moderate decision-making, and level five is your high decision-making. So that really hasn't changed, okay? But what are those elements within the medical decision-making table do you get credit for to give you that level of service, okay? So problems addressed, one element, and this is kind of that first column to medical decision-making is what are you addressing, and how severe is that problem, okay? So number of complexity of problems that are addressed at the encounter. Multiple new or established conditions may be addressed at the same time and may affect your medical decision-making. Symptoms, though, may cluster around a specific diagnosis, and each symptom is not necessarily a unique condition. Again, all of that information is going to be in your assessment and plan. So providers listening in, when you document your assessment and patients are coming in for symptoms, it's so important for you to put a differential diagnosis. This kind of tells us your thought process. What are you thinking it might be? And that also helps to justify anything that you're ordering, reviewing. You know, if you're going to order an endoscopy, if you're going to do a CT, you're going to order labs, et cetera. So it's really important. You know, a patient may have, you know, come in with pain, and you might be ruling out stones or anything like that. So it's very important to put your differentials in there. Gives us that idea of what you're addressing, okay? It may be a couple of different things, okay? Diarrhea, it could be microscopic colitis. It could be a nutritional thing, you know, so put that information into your assessment and plan. Comorbidities, so important, I'm going to talk about this multiple times. Comorbidities and underlying diseases are not considered in selecting your level unless they are addressed or their present increases the amount and or complexity of data to be reviewed or the risk of complications and or morbidity of patient management. So again, back to putting that information into your assessment and plan. Does this patient's comorbidities, the fact that they have coronary artery disease, they're severely morbidly obese, they have COPD, does that impact my decision making? Does that impact the risk of the patient, all right? And again, these are things that we can't assume. You have to give us that information. So the final diagnosis for a condition does not in and of itself determine the complexity or risk. An extensive evaluation may be required to reach a conclusion that the signs or symptoms do not represent a highly morbid condition, okay? And these are just some tips. I'm not going to read this slide entirely to you. These are just some tips on risks, evaluation, etc., where I really want to focus more on our examples, okay? What's a problem addressed, okay? When I'm looking at a note, I'm auditing, I'm, you know, is this a level four, is this a level three? I'm looking at all of those problems that you're addressing, and they should be in your assessment and plan of care. And a lot of times when I'm going through provider's notes, I see up in the HPI that, you know, the patient may have two, three, four things going on, and then when we get into the assessment and plan, some of those things are left off. And I know you've addressed it, and I'm not talking about clustering into one problem, okay? There might be a couple of different symptoms up in the HPI, and it may point to one issue. But those things that may not point to that one issue, make sure you're bringing those into that impression and plan. So a problem addressed or managed is when it's evaluated or treated at the encounter by the physician or nurse practitioner, PA, etc., reporting the service, okay? So if you just say this is the issue, cardiology is seeing the patient for that. We can't give you credit for problem addressed. But if you say, you know, this patient has an extensive cardiac history, this impacts my endoscopic workup for the patient, we're going to have to get labs, we're going to have to, you know, take them off their Coumadin, we're going to bridge, etc., and get cardiology's opinion, then it's addressed, okay? So if you're just turfing it to someone else, it's not a problem addressed. So notation of the patient's medical record that another provider is managing the problem without additional assessment or care coordination does not qualify as being addressed. Referral without evaluation is also not specifically addressed by you. So keep that in mind when you're documenting in your plan of care. All right, so here is a very big table. And again, we're back to straightforward, low, moderate, high. Those are your level 2, 3, 4, and 5. All right, so what are the definitions of the problem addressed within those categories? Well, straightforward is pretty well what it says. It's a self-limited or minor problem. So if you're thinking about your patients, the patients that you see, whether they're new, they're established, there are not a lot of encounters that I look at, that I review, that, oh, yeah, this is a straightforward problem. We're not even doing anything about it. Most of our patients are not straightforward. They're not self-limited. They're not minor. They're now coming to a specialist because maybe the primary care can't figure it out or the patient's frustrated because they're still having these issues, and they're going to see a specialist, all right? So that's more that patient that walks in and says, I have no idea why I'm here. My doctor told me to come see you. I feel fine. And you tell them to go home. Not a lot of our situations. What about low? We do have some examples of low, and again, we'll get into some more examples as we go through these. So this is considered, again, first column decision-making, problem addressed is two or more self-limited or minor problems, a stable chronic illness, or one acute uncomplicated illness or injury. Level four, moderate, a chronic illness with mild exacerbation, progression, or side effects of treatment, two or more stable chronic illnesses, one undiagnosed new problem with uncertain prognosis, an acute illness with systemic symptoms, one acute complicated injury. So again, kind of I think that's really where a lot of our patients reside as far as their problems addressed is moderate, low and moderate, and sometimes high. So that's going to be your chronic with severe. So notice the difference between moderate and high. You've got your chronic with mild exacerbation progression. You have your high chronic illness with severe exacerbation. All right. So think about that. When you're documenting, you guys see a lot of patients that have chronic conditions, IBD, cirrhosis, cancer, Barrett's, GERD even. Are those mild issues going on with the patient today or are they severe? Use those terms when you're documenting. One acute or chronic illness that poses a threat to life or bodily function. So I'm thinking more of a patient that you're like, you know what, you've got so many things going on, we're, you know, we're not comfortable sending you home. All right. So straightforward. Back to straightforward. So again, a problem that runs a definite and prescribed course is transient in nature and is not likely to permanently alter health status. So self-limited, cold, insect bites, self-limited GI symptoms. Again, the patient really, you're not doing a whole lot with them. Okay. So again, stable chronic illness. This is your level three. How many patients do you see that have stable chronic conditions? You know, your patient that comes in with GERD, they're getting a refill. They're doing relatively well. That is low for problem addressed. Now this, for the purpose of defining chronic, conditions are treated as chronic whether or not stage or severity changes. So the difference between uncontrolled Crohn's and controlled Crohn's, it's still a chronic condition. Okay. Now, if it's obviously, if it's uncontrolled, you're going to get into the more of with exacerbation. So you're moderate, you're high. Okay. But it's still considered one chronic condition. So if you don't tell me in your assessment and plan that the patient's ulcerative colitis, Crohn's, anything like that are, you know, there's issues, then we're going to assume that's a stable chronic illness. Same with GERD. You know, if they're not having any breakthrough heartburn, et cetera, it's considered stable. All right. Problem address example again. We're going to get into acute uncomplicated illness or injury. So a recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment and full recovery without functional impairment is expected. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. So think about this, gastritis, could be gastritis, uncomplicated ulcers, cystitis, allergic rhinitis, a sprain, things like that. So they're self-limited. We can treat it. Patient can go about their business, et cetera, again, uncomplicated. Now, how about moderate for problems addressed? Okay. So let's look at chronic illness with exacerbation, progression, or side effects of treatment. So it's acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care, asthma exacerbation, Crohn's, ulcerative colitis with complications or flares, cirrhosis with ascites, could be Barrett's esophagus that is now showing dysplasia. So things like that. So again, back to, let's take like your Crohn's patient or your ulcerative colitis patient. If they're, you know, if they're relatively doing well, they're not in a flare, they're at their baseline, they're responding well to their infusions, that's going to be more of a stable chronic condition. But in your assessment and plan, you say, you know, the patient still is having issues with their symptoms, we're going to keep a close eye on it, we're going to do labs to make sure that they are not vitamin deficient, things like that, then that would go more into that moderate level four that with exacerbation, progression or side effects of treatment. So it's so important for you to bring that information into that assessment and plan. And sometimes I see that sometimes I'll see the HPI that says, you know, the patient has a XYZ, however many years of ulcerative colitis, they have all these issues, they're not, you know, doing well, they their their diarrhea is worsened or whatever. And then the assessment says, ulcerative colitis, and then continue the same treatment. If you are ordering new medications, you're shortening their infusion schedule, you're obtaining labs, you're doing an endoscopic workup, there should be reasons in your assessment and plan as to why, not just that it's time for it necessarily, it's just that, again, patient has symptoms, abnormalities that lead us into a different treatment, or again, endoscopic workup, etc. Let's take a look at undiagnosed new problem with uncertain prognosis. What do you think about that? Okay, we have a lot of patients that come in to see us, and we're not really sure what's going on with them. Okay, what are we going to do about it? A problem in the differential diagnosis that represent a condition likely to result in high risk of morbidity without treatment or workup. So remember, when I said in the beginning of the presentation, putting in your differentials, tell us your thought process, tell us what you're thinking about this issue. Okay, CT scans that show abnormalities of the GI tract. That's a big one that we see patients for. Abnormal LFTs, that's a huge one. Patients come in, they have, you know, their liver function tests are high, their transaminase, etc. What are we going to do about it? Well, most of the time, we're not going to just tell the patient to, it'll be okay and send them on their way. We're going to do our own set of labs, we may get a CT scan, we may do, most of the time, we're doing a workup on these cases. Okay, so again, putting in your differentials helps with this category to support that moderate for problem addressed. Acute illness with systemic symptoms. So this could be your colitis, not your IBD, necessarily. But you know, if the patient's having an inflammation in their colon, you're putting them on a medication, etc. Also, polynephritis, pneumonitis, COVID-19 with symptoms. That is another one that can be thrown into this category. Then we have acute complicated injury. All right, so this is more of like head injuries, these are actual injuries, I'm not going to talk a whole lot about this for GI. But let's look at high. 99205215 for problem addressed. So again, two different categories here. The first one, chronic illness with severe exacerbation, progression, or side effects of treatment. Okay, says that have a significant risk of morbidity and may require hospitalization. Severe COPD exacerbation, severe IBD, liver cirrhosis that has progressed into liver failure, things like that. So again, making sure that you document this information in your assessment and plan of care. We can only give you credit for what you tell us, what your thought process is, what you're doing about it. So if it's severe enough to warrant an ER visit, a hospitalization, make sure that you document that information. Threat to life or bodily function. GI bleed with acute blood loss, anemia, severe acute pancreatitis. There's all kinds of GI things that GI issues that, you know, may lead the patient to be transferred to the hospital. Most of the time, though, when they're seen in clinic, it's probably not going to be this category. But you do have some patients that walk in and you're like, oh my gosh, you need to go to the hospital. So again, making sure you document that information. Let's take a look at data. So we really dove into some of those clinical examples of a problem address. That's that first column to medical decision making. We're going to talk about the second column of medical decision making, which is your data. This is all the information that you do. You do a lot of work with ordering, reviewing, speaking to other providers, speaking to the patient's spouse about their care. And are you putting that information into your notes so you get credit for it? This category can also increase that level of service that you're billing out. All right, so we've got some definitions by the AMA. What's a test? What is considered unique? What is considered combination of data elements? So we're going to talk a little bit about this. So if you're considering a test, you're going to order a test. What's a test? Imaging, lab work, psychometric, physiologic data. It says a clinical lab panel is a single test. So if you're actually ordering a liver panel on a patient, that's one test. But if you are ordering a, you know, a liver panel and then something else for lab, that's actually two different tests. So it says the differentiation between a single or multiple unique test is defined in accordance with the CPT code set. Okay. So if it's actually categorized as a different CPT code for each test that you're ordering, you get credit for each one of those that you're ordering. So how important is it? Again, back to documenting in your assessment and plan. Everything that you order and what are you ordering? A unique test is defined by the CPT code set. So when multiple results of a same unique test are compared during your visit, it's only counted as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. So for example, a CBC with differential would incorporate the set of a hemoglobin CBC without differential and platelet count. Okay, so you have to kind of know the differences between are we going to count this as a one single test or all of these individual. Combination of data elements. So a combination of different data elements, for example, a combination of notes reviewed, test ordered, reviewed, independent historian, etc. allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered plus a note reviewed and an independent historian would be a combination of three elements. So that's you get to kind of add them together to determine that overall straightforward low moderate high. What is the definition of and again, this is back to that polling question. Okay, external records communication and or test results are from an external provider facility or healthcare organization. Alright, so what happens if you spend 20 minutes seeing the patient and maybe even before they walked in the door that morning, you spent 20 minutes reviewing your internal records because you haven't seen them in six months, you haven't seen them in a year? Well, it's not going to count towards data. But what could it count for? Time. Time driven visits. Remember, when you document time, you get to count the total time of the encounter. So you may not get to include your internal records for data column for decision making. But again, it could be a scenario where you're doing you're documenting and billing by time. Alright, what about independent historian? This is an individual and I know you guys encounter this a lot. Parent, guardian, surrogate, spouse, witness, who provides a history in addition to a history provided by the patient. So they might be unreliable, they may have developmental issues, dementia, etc. Okay, or because of a confirmatory history is judged to be necessary. So in cases where you need additional information from that person, make sure you document that. Okay, spouses with the patient today, I've gathered additional history from that spouse, XYZ. This is what I got from that, from that spouse. Okay, that'll give you more credit in the data column to decision making. Another area of data is independent interpretation. What does that mean? It is the independent inter it's the interpretation of a test for which there's a CPT code. And an interpretation report is customary. This does not apply when the physician or other qualified professional is reporting the service themselves. Alright, so if, for example, let's say you, the patient had a capsule endoscopy. All right, and you're doing an interpretation of that capsule endoscopy, you couldn't, you cannot count it in your level of service, because you've already built separately for that service. But let's say a patient comes in, and they bring their EKG report, they bring their labs, they bring something from an outside source, and you're doing an interpretation of that test. That's when you can count it, but you have to document it. You don't have to have a formal interpretation in your note, you just have to comment on it. Patient brought their EKG with them today, this is my interpretation of it. Appropriate source. So this is another area of data. It is an appropriate source includes professionals who are not healthcare professionals, but may be involved in the management of the patient. So attorney, parole officer, case manager, things like, you know, people like that. So if you're speaking to those individuals, make sure you document it as well in your note. Analyzed. So when do you get credit for analyzing a test? Alright, so tests ordered are presumed to be analyzed when the results are reported. Therefore, when you are ordering a test during an encounter, they are counted at that encounter. Tests that are ordered outside of an encounter may be counted when they come back and you analyze that test. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly PT times would count for one PT order reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test at that encounter. But keep in mind, any service for which the professional component is separately reported by you guys, it is not not counted in the data category. All right, it's it's off the table because you're already getting credit. You're already getting an RVU for a formal interpretation of that test. Okay. What about discussions? Do you talk to other providers? About the care of the patient? It requires an interactive exchange. The exchange must be direct and not through your clinical staff, trainees, etc. Sending chart notes or any written exchanges that are within progress notes does not qualify. The discussion, though, does not need to be on the date of the encounter, but is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous, so it does not need to be live real time in person, but it must be initiated and completed within a short time period, within a day or two. So they give you very good guidance on that. So here's the breakdown. Again, big table, straightforward for data, low, moderate, and high. Okay, minimal or none is straightforward. So if you don't have a test, you don't do any kind of data in this encounter, or you maybe you do one, it's going to be straightforward. All right, low. Low is a combination of two of the following. Review of external records, review of a test, ordering a test, or you might not do any of those in Category 1, and you might only just do Category 2. Independent historian. So again, you may not order anything, review anything, but the patient brought their spouse with them today, and you're getting information from that spouse. You already met the low category for data. Moderate. So one of the three categories. Category 1, again, you're talking about tests and documents, you have to have three of them. Or assessment requiring an independent historian and discussion of management or test interpretation. And then the only difference between moderate and high is you have to have two of the three categories met. Alright, so again, straightforward. That's going to be your lower level, level 2s. 202, 212, no data reviewed. Analyze is required for this level of service. Now three. Any combination of two of the following. Again, we just broke that down. Example, provider orders both a liver pack panel and a CT scan today. Alright, I've met two of that first column. So I've got low for data. Moderate. Three. Again, tests for three. Or independent interpretation or discussion of management. So example, provider reviews the patient's records from primary care's office. Orders a CBC and a CT scan. That's moderate. You've met moderate for complexity of data. High is level five. Any combination of three of the following. And And independent interpretation or discussion of management. So example, provider reviews the patient's records from their primary care's office. Orders a CBC and a CT scan and discusses EKG results with primary care that was done in their office last week. So an extensive amount of data there. Practice pearls. Alright, this is the end kind of the summary. The HPI tells the story of the patient, whether new or established, put all pertinent information in this area regarding current symptoms and abnormalities. Data. Sometimes whenever you do like an external record review or you speak to a spouse, etc. You put this information up in the HPI and that's okay. As long as it's in your note. Make sure you document it. So we give you credit for it. The impression and plan should also contain what you're addressing what you think it might be again differentials. Why you are ordering additional tests procedures, etc. Instructions you give to the patient, caregiver, and any other recommendations. List all conditions that you're currently managing and or that play a role in the care of the patient. If not documented. No one knows what you did or what you're doing. You should get credit for the work you do and the level of service that you're billing. But if it's not documented. I don't know what you did. This is not just for supporting your level, but for medical necessity and also pre authorization of tests and procedures. All right. So when you're trying sometimes when you're trying to get a CT authorized. Guess what happens. The nurses or whoever's pre authorizing this service is looking at your note to figure out why you're ordering this information. And when it's vague. Guess what happens. They go back to you and go, hey, can you give us another diagnosis or what's the issue. Okay, so please make sure you're very specific and you put this information into your impression and plan of care.

E&M guidelines

complexity of problems

data reviewed

problem addressed

clear documentation

risks in medical decision making

levels of data