Thank you, Dr. Lindenberg, and welcome, everyone, and yeah, there are going to be some changes coming up in the next two years, and we've seen some changes in the past year, especially with the new E&M guidelines, so we welcome your questions, and there's times for those after each one of our sessions, and so let's go ahead and get started. All right, so we got something to maybe wake you guys up a little bit here, so good morning. Are you ready to go? Are you in jammies? Are you fully dressed and ready? Are you kidding me? I'm still in bed. Are looking good on tap. All right, 50-50. All right, next question, and how many of your members of your team are participating in today's course? I know this is day four for some of you, but this might be day one for some of you as well, so just let us know. We'd like to hear. Okay, all right, wow, awesome. All right, guys, well, let's begin. So what we're going to talk about in this first session is the extension of the public health emergency. I think most of you are aware of this. Changes to the 2022 ASC fee schedule, changes to the 2022 physician fee schedule, the new CPT codes for 2022, some payer updates, and then ICD-10. So let's talk about the public health emergency. I think you guys are all aware of this. This is like the 300th extension, I think, but no. The latest renewal became effective October 18th. It's going to continue for 90 days and is going to remain in effect at least until January 16th of 2022, and expect that that's going to go on again for another 90 days after this. CMS has published some information, and I'll talk about that in the final rule, but, you know, they've extended some of their policies during the PHE until the end of 2023. So I think rather than keeping renewing and renewing and renewing all this, it's trying to keep it constant for some point in time. Now our commercial payers, not so much. They kind of follow along with the PHE guidelines, and so you definitely need to check and update your policies, not just for telehealth, but also for all of our office services as well. And, you know, this also goes along with patient co-pays and deductibles too. So let's talk about the 2020-21 ASC update, but this is actually going on to the 2022 ASC fee schedule. So this was actually published November 6th, and there is an overall 2.0% increase in ASC fee schedule. So we've gotten a little bump every year. There were 11 codes added to the ASC payable list, and none of which are RGI. ASC measures 1 to 4 are still suspended until 2023. I just want to make a comment on that. So those are some of the G8-907 measures, and we still see some of them are being submitted when we do reviews. Of course, these are for the quality measures, but just keep in mind that if the measures are suspended, they really should not be submitted. And sometimes when you do stuff that has actually been on suspension, it can look like a compliance issue. So just be aware that those measures are not to be added to your claims. It's not going to be a penalty, all right, but it's just kind of a little trigger to a payer that's like, hmm, you guys are really not compliant at this point because you don't have to submit these right now. So just be kind of aware of this stuff. It's just also the same thing as utilizing modifiers inappropriately. So I'm going to talk about that a little bit later today as well. ASC measures 9 and 12 for GI endoscopy and ASC, all right, those are still in effect, and there is a new ASC measure, ASC-20, for COVID-19 vaccination among healthcare personnel, and it will measure the percent of healthcare professionals eligible to work in the ASC for at least one day during the reporting period who received a complete COVID-19 vaccination course. It says the measure specification looks an exception for those with contraindications to COVID-19 vaccinations that are described by the CDC. So there are two links on the bottom of the slide that will actually take you to these measures and give you much more detailed information. So let's talk about the physician fee schedule. So on November 22nd, CMS issued a final rule, the policy changes for Medicare under the physician fee schedule that go into effect on or after January 1st of 2022, and if you realize, this is about a month earlier than last year's release, and this is in line with when we normally see the release of the fee schedule. So there's two links on here. This is one that's got the fact sheet and then the full notification notices. So if you want further information, download that, those two links. The conversion factor, now with the budget neutrality adjustment to account for changes in RVUs, and then it was an expiration of the 3.75% temporary payment increase that we got last January, the conversion factor is going to drop to $33.59 per RVU, which is a decrease of $1.30 from the current conversion factor of $34.89. And for those of you that are listening in that don't really know what an RVU is, it's a relative value unit. It's factored in by three components, the physician work value, the practice expense, and the malpractice expense. So three things added together give you your total RVUs, and that multiplied by the conversion factor gives you the national approved amount by Medicare. When you go actually look into your own approved fee schedule for Medicare, it's based upon the locality in which you practice. So if you want your full approved amounts, based upon your locality, you'll need to go into your Medicare carrier's fee schedule and download that information. So there is a new rule for split or shared E&M visits. And CMS's point on this is we are refining our longstanding policy for split or shared E&M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the calendar year of 2022, the final rule, we are establishing the following. The definition of split or shared E&M visits is E&M visits provided in the facility setting by a physician and an NPP in the same group. Further information will be given to you a little bit later. The visit is billed by the physician or practitioner who provides the substantive portion of the visit. In other words, whoever documents the most. By 2023, the substantive portion of the visit will be defined as more than half of the total time spent. Right now, it is for the substantive portion can be the history, physical exam, medical decision making, or more than half of the total time, except for critical care, which can only be more than half of the total time. So split or shared visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services. So there is definitely a difference in the definition of split or shared. A modifier is required on the claim to identify these services to inform policy and help ensure program integrity. And for your information, the modifier has not yet been designated. All right, I imagine that we'll see something in the next few weeks or so. Documentation in the medical record must identify the two individuals who perform the visit. The individual providing the substantive portion must sign and date the medical record. All right, so telehealth services. So as CMS continues to evaluate the inclusion of telehealth services that were temporarily added to the Medicare fee schedule and telehealth service list during the pandemic, we finalized that certain services added to telehealth will remain on the list through December 31st of 2023, allowing additional time for us to evaluate whether the service should be permanently added to the Medicare telehealth service list. I mentioned that earlier. So we finalized that we will extend through the end of 2023 the inclusion on the Medicare telehealth services list of certain services added temporarily. We also have extended inclusion of certain cardiac and intensive cardiac rehab codes. So again, this will allow for more time for CMS and stakeholders to gather information and to reduce uncertainty regarding the timing of our processes with regard to the end of the PHE. And they're also adopting coding and payment for a longer virtual check-in service on a permanent basis. And I think we all know that the telehealth business has been highly successful, and we know at some point that certain services will remain. So CMS is amending the current definition of interactive telecommunications, which is defined as multimedia communications equipment that includes at a minimum audio and video equipment permitting two-way real-time interactive communication between the patient and distant site physician or practitioner to include audio-only communications technology when used for telehealth services for the diagnosis, evaluation, and treatment of mental health disorders furnished to establish patients in their homes under certain circumstances. CMS is limiting the use of audio-only telecommunications to mental health services furnished by practitioners who have the capability to furnish two-way AV communications, but where the beneficiary is not capable of or does not consent to the use of two-way AV technology. CMS also is finalizing a requirement for the use of a new modifier for services furnished for audio-only communications, which would provide to verify that the practitioner had the capability but instead used audio-only due to beneficiary choice or limitations. All right, so again, this was just released. There is no modifier yet assigned to this. We are going to get further information. We've had a couple questions on this. Well, is this just limited to mental health? And sounds like it is, but I have a feeling that the audio-only services are going to be also to our patients as well. So again, keep your ears and eyes open for further information, because again, this was just released about 10 days ago. The new CPT codes for 2022. We have a new code for the POEM, 43497, lower esophageal myotomy, poor oral endoscopic myotomy. And of interest, it's not in the upper GI endoscopy codes. It's under other endoscopic procedures. It is put into a 90-day global period, and it's worth a little over 23 RBUs. There is a new code for the hepatitis B vaccination, three antigen use. There is a new code for GI imaging, capsule endoscopy of the colon. And it says incidental visualization of the esophagus, stomach, duodenum, and or ileum is not reported separately. Then we have some new codes on chronic care management services and 99424 and 425 on principal care management services. And Dr. Littenberg will be going over those later with you. Another code for 99426 for principal care management by clinical staff and 427 for each additional 30 minutes of clinical staff time. Then we have some category three codes, which of course are temporary codes. And this is a esophageal gastro duodenoscopy transnasal with specimen collection with biopsy and insertion of intraluminal tube or catheter. All right. So anything that has a T behind it, we pretty well know on the physician side, we are going to end up having to bill as an unlisted procedure code, but on the facility side, there are reimbursement and fees associated and assigned to these T codes. So let's talk about some payer updates. And I was just wondering, this is an example of one of our practices and how they got policy actually changed with Novataz. And I know some of you listening are under Novataz policy and I know some of you are not, but this is actually a policy that was revised last year. And when they revised the diagnostic colonoscopy policy, they did not include Crohn's of the small intestine without complications, Crohn's unspecified without complications and ulcerative colitis unspecified. All right. And this is the reason why, this is what Novataz's response is. This is in response to a letter from a practice. And it said for K50.0 for Crohn's disease of the small intestine, the colonoscopy cannot reach the small intestine. All right. Furthermore, the policies for diagnostic colonoscopy, if the patient is not having any complications or symptoms, it would not be considered diagnostic, more of a routine screening, which is not covered. All right. So obviously whoever made the policy doesn't understand how far the scope goes and it does go in to the small intestine. So K50.90 also says this would not be appropriate since it is an unspecified code. All right. And if the patient is having, not having any complications or symptoms, it would not be considered diagnostic. So we've been talking about this for years, the use of nonspecific diagnosis codes and how that can affect whether or not your claims get paid. So K51.90, ulcerative colitis unspecified, it's the same rationale. K51.911 to 919, which unspecified with complications, again, these are unspecified codes. And then they say, please keep in mind the purpose behind ICD-10 codes is specificity and using more specific ICD-10 codes that are available rather than using unspecified diagnosis codes. So your interest in the Medicare program is appreciated. All right. So this was Novataz's response to the practice. This is the practice response. All right. So it says colonoscopy cannot reach the small intestine. This is issue number one. Back to Novataz. A colonoscopy does evaluation portion of the small intestine. The terminal LM is often intubated during colonoscopy. Patients with small bowel Crohn's and the distal bowel can be evaluated during colonoscopy. Number two, their response was patients with IBD may be asymptomatic, but the only way to assess whether their medication regimen is adequately controlling the disease is to take random biopsies diagnostic and evaluate how well the disease process is being managed. Number three, random biopsies are diagnostic. It would not be appropriate to bill a screening if the intent was to check for disease control. Number four, random biopsies are never obtained during a routine screening. Biopsies during a screening are only taken of abnormal appearing tissue. The biopsies taking during IBD clones are often normal appearing but can show active disease microscopically. There are times, number five, when the type of disease has not yet been established and an unspecified diagnosis is the only option. Our providers do not assign a diagnosis until it is confirmed as required by ICD-10 coding guidelines. If the provider knows it is IBD, but the extent is not yet known, then it would be inappropriate to assign one of the more specific codes. There did not seem to be adequate understanding of the disease process of IBD when developing LCD. The disease is never cured unless the colon is removed. Symptoms are kept under control to varying degrees with medication. Because the patient with IBD does not have symptoms does not mean they do not have active disease. Please reconsider the excluded diagnosis listed in the original email. Very thoughtful response to Novataz by this practice. So this is Novataz's response. This is in request. You request that Novataz add these codes to local coverage article. All right, we have completed a review of your codes and our contractor medical director has determined that some of the diagnosis codes requested can be added. Please continue to watch our website for the revision to be posted. Well, just for you to know, this week it was published. They're adding all of the diagnosis codes to their policies with the exception of K51.90, which is ulcerative colitis unspecified. All the other ones have been added. All right, so I'm just, you know, when we look at policy and we don't like it. All right, there is something you guys can do about it and that's the proper steps. And I just wanted to make sure that you guys are aware that this is, it does happen. You know, so we get lots of questions. It comes through the ASG coding hotline of what we can do. And sometimes we forward them to ASG, but most of the time it does help when you guys are actively involved in this. And obviously, if you want to take an example of this, that would be exactly how to write a response to a payer to get them to revise policy. You have specific clinical guidelines to back you up and they do listen. All right, so, all right, UnitedHealthcare. As of October 1st, UnitedHealthcare is following the ACA guidelines and rollout screening at age 45. I'll talk more about the colonoscopy screening guidelines a little bit later when we get into screening versus diagnostic colonoscopy. And then Cigna also, as of October 1st, is following the ACA guidelines and rollout screening. All right, so this is a new policy. Anthem's policy on multiple procedures for their facility. All right, the effective date is January 1st of 2022. And if you guys are not aware of it, you need to get online and find out if this policy does affect you. So this is a new reimbursement policy, multiple and bilateral surgery processing for the facility side. All right, so this is ASC. And it says, dear provider, beginning with dates of service on or after January 1st of 2022, Anthem Blue Cross and Blue Shield will implement a new facility reimbursement policy titled multiple and bilateral surgery processing. Anthem allows reimbursement for only the primary or highest valued procedure when multiple or bilateral procedures are performed on the same day, our same session, and at the same place of treatment when billed by a facility. A single surgical procedure is subject to multiple procedure reduction guidelines when submitted with multiple units. So it says, for more information, view this policy online. Go to anthem.com, select providers. Under the provider resource heading, select policies, guidelines, and manuals. Select your state. Under the reimbursement policies heading, select access policy, and follow this to the T. All right, and then search for the policy that you would like to view. There's not 52 states and territories listed on this policy. All right, there are just, I think, 12. All right, so if you go in and you are practicing within the state, then you click on it and find out what your guidelines are. All right, when this was first published, actually, this was released on October 1st, and somebody had sent me this and I looked on it, and there wasn't any policy listed just yet. It's now on there. So every state that's listed, if you click on this, it will give you this information. And it basically states they're only going to pay the highest valued procedure. So Aetna consultation update. Starting December 1st of 2021, Aetna will no longer pay office consultation codes, 99241, 242, and all the way up to level five. And I think, you know, I'm basically putting my two cents worth into this, but when we've had the new changes in the E&M guidelines, the E&M guidelines only actually covered the new patient and established patient codes. So the medical decision-making criteria for consultations still reverted back to our old guidelines and our documentation requirements. So they are still going to pay inpatient consultation codes, but they are not going to pay outpatient. All right, so UnitedHealthcare CITUS service update for screening colonoscopies. The effective date is October 1st of 2021, and I highly urge all of you that are under UnitedHealthcare's guidelines for this, they've had this policy up for diagnostic colonoscopies as well, all right? But they're specifically telling you there are certain criteria that have to be met in order for this to be covered in the hospital situation. So planned preventive screening was performed in a hospital outpatient department. All right, only considered medically necessary for the individual who meets any of the following criteria. And if you look through this, this is very detailed. Advanced liver disease, male score of over eight. Cardiac arrhythmias, patients are still symptomatic despite medication. COPD, all right, FEV of less than 50%. Coronary artery disease, PVD. And if you look at this, this reflects if a patient's had a stent placed, a drug eluting stent placed within a year. Any type of developmental state or cognitive status that warrants using a hospital outpatient department. End stage renal disease. A history of CVA RTIA within the past three months. And when we go into anesthesia guidelines in particular and the difference between ASA3 and ASA4, this is pretty well right on the money. History of MI, recent event within the past three months. Again, back with stents placed within the past 90 days. Ongoing evidence of myocardial ischemia. Poorly controlled asthma, severe valvular disease. Poorly controlled hypertension, sleep apnea. But not just sleep apnea, not just, it says moderate to severe. Uncompensated chronic heart failure and uncontrolled diabetes with recurrent diabetic ketoacidosis or severe hypoglycemia. This is specific. These are specific criteria. So on a screening colonoscopy, I know some of you guys are listening and you don't necessarily bring all these patients in. But most of the time you do bring some of these patients in because what? They're high risk. All right, so if you're bringing them in to determine whether or not they meet the criteria or if their condition is so severe that it's risky to perform it, regardless if you decide to do it or not and your place of service is outpatient hospital, your documentation better contain this information. Remember that we do have to preauthorize colonoscopies, whether they're done for screening or diagnostic purposes. All right, to find out first of all, if the patient's eligible for it. Most of the time we get told there's no preauthorization required as long as it's an outpatient service. And you would think, well, outpatient hospital is still outpatient, not for some of the payers anymore. All right, one of them, Anthony was another one that doesn't quite automatically approve outpatient hospital services unless the patient meets those requirements. So whoever's seeing the patient and taking the history in your office needs to ask the specifics if this patient is going to end up being in the hospital setting. All right, so just very important. I know some of your patients just want, some of your patients have their own opinions and they just want to have it done in the hospital setting, but it may not be qualified, it may not be approved. So just make sure that your documentation is there. And so again, this is a little bit more information for their site of service update for screening and what the definition is. And then they also give you the definitions of obstructive sleep apnea. And again, look at the detail. And AHA or RDI statuses in particular. So would you know all that information? Do you have access to all of that information? And does your patient have all of this information? So applicable codes for screening, 45378, 45380, 45381, 45384, 85, G0105, and G0121. All right, so just of interest here, we do have some questions as to, when we do preauthorization and say we preauthorize the screening, but during the colonoscopy, we ended up removing a polyp by snare, UnitedHealthcare didn't approve it. All right, because when you deal with UnitedHealthcare, you need to preauthorize all the procedures that might be considered eligible or done during that procedure. Now, do you notice one of them on there is not 45390, which is an EMR? All right, so as far as EMR goes, endoscopic mucosal resection. All right, so some of your providers, if they go into screening and they see this broad-based polyp, and they do an EMR technique on this one, when we end up putting a PT modifier, if it's Medicare, R33 modifier on it, because it was a screening converted to a diagnostic or surgical, we have seen some from UHI and UHC and some other payers in particular that say 45390 is not approved, or they want further information. First of all, they want to make sure that the documentation does reflect an EMR, but do you notice that 45390 is not on this list? All right, so again, if there is a possibility that an EMR might be done on this, you do need to get it pre-authorized, but we've had several payers that, and several, not payers, excuse me, several of our practices say that they have appealed and UnitedHealthcare says, no way, they're not going to cover 45390. All right, so that's something that we can appeal with our physicians and with the medical directors as whatever, to make sure to get some of these policies revised. So the diagnosis codes that also are applicable are listed as here. So we've got your average risk and you also have family history codes that are eligible. Now let's talk about the ICD-10 codes. We've got some 2022 ICD-10 codes. We did get some new codes for toxic encephalopathy. We have a new code for esophageal polyp and EG junction polyp and other specified diseases of the esophagus. So we got new polyp codes, like we got colon polyps and stomach polyps, et cetera. So if they're not adenomatous, if they're not neoplastic, then these are the codes that we want to use. The K22.8 code is now five digits to eight, nine, which is other specified disease of the esophagus. We use this code quite a bit. So if this is a area that's ridged, if it's erythematous, anything like that, and pathology does not come back as abnormal, then K22.89 is definitely an appropriate diagnosis code to use. K31.A0 and A11 to A19 are some new gastrointestinal metaplasia codes without dysplasia, and it's very site-specific. And then K31.A21, A22, A29 are with high-grade, low-grade, and with dysplasia unspecified, which are not site-specific. We also have Sjogren's syndrome with GI involvement, and we have some new specific cough codes. So R05, which was one of our last few three-digit codes have now become four-digit. And we do use cough, all right? A lot of times with GERD and potential aspiration syndrome symptoms in particular. So we have acute, subacute, chronic, cough syncope, other specified cough, cough unspecified. All right, so please be specific to the type of cough. I have a feeling most of the time we have a chronic cough issue. But again, if you just say cough, it will be cough unspecified. The use of nonspecific ICD-10 codes. All right, well, when we saw the policy for Novitas, that's one of the things they said, that, you know, ICD-10, the purpose of it was to be specific in nature. We are still seeing some payers out there pending claims, doing errors, and the error and the denial reason is lax specificity. Now, I just wanted you guys to keep in the back of your mind that the average cost for any type of pended or denied claim is around $40. Because what we have to do, we have to figure out why it is. We have to resubmit, or we have to cough. We may actually even have to start over depending upon the type of denial that we have. All right, so again, be specific in your documentation so that we can get the claims through and paid without denials. We have some new feeding difficulty codes. All right, so R63.3 is now five characters. And of course it becomes 0.30 if it's just feeding difficulties listed. Pediatric feeding disorder acute and chronic and other feeding difficulties are the now four diagnosis codes for feeding difficulties. All right, we do know with the EGD policies that we have out there with different commercial payers that feeding difficulties isn't listed as an approved diagnosis code for PEGS. All right, not on all of them. All right, so just make sure why does the patient have feeding difficulties? Is there dysphagia? Is there some type of eosinophilic esophagitis? Is there a cancer diagnosis? What's going on with the patient? So be specific as to why the patient does have feeding difficulties when you list that. Abnormal findings of blood amino acid level. There's some adverse effect of cannabis codes and synthetic cannabinoids. And there actually were way more cannabis ICD-10 codes in there. I did not put all of those in here, but I just wanna make sure that you guys are aware of these codes. When we do reviews, we've been seeing more patients with nausea and vomiting. And oftentimes in the impression implant was due to marijuana use or cannabis use, et cetera. So if the patient does have an adverse effect of cannabis, this is an additional diagnosis code to add in addition to the symptoms. There is a new code for post COVID-19 condition unspecified. And the description of this is actually the patient is no longer symptomatic, is not in the acute phase anymore of COVID, but still has a condition that's being attributed to COVID-19. So we have some new social determinants of care codes, less than a high school diploma, some water issues, homelessness issues, food insecurity, housing instability, other problems related to housing and economic circumstances. And then last but not least is encounter for immunization safety counseling. I had a couple, I actually had a question this past week is we've been doing a lot of education with our practices on COVID vaccinations. And not even that, for those of you that have hep C patients or immunocompromised patients, you're talking about them getting immunization. So if that's an additional service that you're providing during your visit today, this is another diagnosis code that you can add. So I'm just gonna go back to these housing instability codes and Kristen's gonna go into the decision-making guidelines, new guidelines that moderate risk, which is one of the elements of decision-making can be dependent upon the patient's issues with social determinants of care codes. So it's not just the housing codes and there's also financial reasons they can't afford their medicine. They have home issues, marital problems, problems with kids, et cetera. There's a whole bunch of codes in the Z55 to Z77 range in there. They're excellent diagnosis codes to assign. If you don't assign them on the claim, it's okay. You don't have to assign them on a claim but put this into your plan of care because if you feel that their disease process is being hindered by these social determinants in particular, make sure and bring that in your prescient plan. It does add to the overall risk of the patient. So don't forget about that. Sometimes we see this in the HPI and that's important. As long as it's in your notes somewhere, it does factor in to the development of your treatment plan. All right, so there are more issues that impact GI practices. We're gonna be talking about ICD-10 and HCC risk adjustment. We're gonna be talking about the EMM review on medical decision-making. That's still, I think, still has a lot of questions to be answered on this. We're gonna be talking about screening versus diagnostic. Medical necessity is the key. Pathology and ancillary services, anesthesia services, and our top issues. And then Dr. Lutenberg's gonna give us a look into the 2023 EMM services. So stay tuned and that's not all we're gonna talk about today. So at this point, I'm gonna turn this over to Kristen. I know we're a little bit early, but let's go ahead.

healthcare industry changes

public health emergency extension

CPT codes for 2022

payer updates

ICD-10 codes changes

documentation and coding

specificity in diagnosing and coding