Okay. We're going to have Dr. Littenberg present. All right, here we go. Okay. So what I'm going to talk about is not just what's probably new in 2023, because we don't know a lot of that, but I'll show you some details of what we think we know. And why it's particularly important to rethink about what you've been doing and maybe think outside the box. Some of the services that you may not be providing that you could. Some that you're providing, but maybe you could do better. So I illustrate this thought with the photograph. I took in death Valley. A couple of years ago, Dan DeMarco was one of our. CPT advisors now is actually on the rock. As a gastroenterologist. And he was posing there. Taking a, as I took an image of the setting moon with the monkey way above. We just have to think in somewhat. Unusual ways in order to deal with some new weird realities of payment reimbursement. I illustrate this. Because this shows the discrepancy between what would have been a normal rate of medical inflation. And what would have been a normal rate of medical inflation. And now we're looking at yet another potential 3.75. Congress doesn't act, zero further updates through 2025, the 2% Medicare sequestration resuming next year unless Congress puts it off and now it's extended to 2030, meaning after the proper fee is determined based on the conversion factor, Medicare takes another 2% out of your check because of earlier budget problems and because of yet further congressional rules called pay go, meaning if the total of payments for Medicare is beyond the projected budget many years ago, an additional 4% sequestration might be taken. So we're talking about potential of about a 10% cut in Medicare fees and if your fees are tied to Medicare in your other contracts, you're talking about potentially at least roughly 4% further reduction. So we really have to be careful about what we do. One of those simpler things is realizing when you've done a more complex service and taking credit for it. Many gastroenterologists do a lot of level five services and yet we've tended to underbill for them. Back in the early 1990s, level fives constituted about a quarter of our practice billings and went down steadily until it's been 5% or so in recent years. And this is because we had documentation requirements that were somewhat onerous and there was just a lot of fear of overbilling and getting held responsible on audits if your documentation didn't meet those standards. But if you think about the new ways of billing, it's not really hard for a lot of our complex patients to bill appropriately for a level five, whether you base it on time or base it on complexity, mostly on complexity of medical decision-making and substantial incremental difference. And if this is done for even four patients a week over a 46 workweek year, a fair amount of increased revenue there. All right. So adding a couple of slots, if your schedule can allow for it, probably adds another 10,000 or so in revenue. If you're doing tobacco cessation counseling and you forget about ever billing for it, and yet you spend a few minutes, three minutes, five minutes, eight minutes, you know, there are ways you can bill for that. Many practices are really doing elements of chronic care management and haven't been billing for it or could use a service that they set up in their larger practices or even contract for outside their practices and have shared responsibility for chronic care. I'll go into a little detail on that. Similarly, prolonged services are things we often do when we're doing reviews of large outside medical records. And I'll talk about that and the requirements. Basically for a half hour or more of that kind of service, pretty substantial reimbursement. In the other talk I'll give a little later, I'll go into more detail about telephone services and services performed online. This may be an exchange of portal messages or a mix of portal messages and phone calls. But these are being paid quite nicely during the public health emergency. Whether these will sustain as we go forward after the pandemic remains to be seen, but there's a good chance it will, at least in Medicare, maybe in private payers. A lot of folks are not doing hemorrhoid banding in their practices, not a very complicated thing to learn and a high volume of patients pays well. A lot of us when we do colonoscopy, I still see a lot of people doing biopsy removal of small polyps, which has already been established that it's better quality to try to do cold snaring, which is also very safe. And there's actually a difference in the physician fee, which can easily add up over a course of a year. So folks who haven't learned cold snare technique and adapted it for dealing with small polyps would be well off to do that. If you have a pathology lab as part of your practice, a lot of docs are still not really doing appropriate biopsy technique for long segment Barrett's, where more bottles can be generated appropriately, good quality. Again, distinguishing the cardiac from the distal esophagus sometimes requires separate biopsies, separate biopsies sometimes from the areas around polyps in the stomach to know what sort of gastritis or pathology may underlie it. Adequate segmentation of all sort of colitis biopsies, appropriate biopsies in GERD patients, trying to find those patients with eosinophilic esophagitis. So there are a lot of things that your pathology lab, if they're part of your practice, should be talking with you about, making sure you're doing proper biopsy technique, polypectomy technique, which is both better quality and turns out to be better reimbursement. Other things that many practices do, but many more could do, there are techniques to evaluate patients who have chronic liver disease, especially in this era of obesity. FibroScan and some emerging technologies like Velocure can examine these patients. Per service, not a very high rate, but the numbers of patients that are being done is quite substantial. My own practice, I read about 30 to 40 FibroScans a month for the patients generated pretty much through my own group of four or five. And we have FibroScan available in many of our own offices. We move the equipment around because it's expensive, but it's also portable. So we have it one week a month and turns out to be a very worthwhile thing to help evaluate patients as well as another source of revenue. Some practices will prepare to evaluate and sell certain supplements, which patients are often very much into non-prescription therapies. It's not a high volume and revenue builder, but it is very popular with patients and medically a lot of these supplement products are appropriate. A lot of practices could be giving out colon preps they have instead of just writing prescriptions for everybody. If your lab is suited for it, doing pathogen panels, immunohistochemistry, breath tests are all good services a lab can add. Doing in-office ultrasound, which can again be portable, brought office to office on a particular day of the week or the month. Adding Bravo to the ASC is feasible. It has to be done carefully how you do it and how you charge for it. The point is if we don't do anything different, this is the image of what we may wind up with. So I'm going to talk about some of the things that are old and some of the things that are new or newer and some of the considerations for them. And I'll go into a little detail on all of these. Again, there's more detail in the slides than I'm going to talk about verbally, but it's all there. So let's start with prolonged services. One of the codes that exists but is difficult for us to use are the prolonged service codes that can apply to an E&M visit. The problem is you have to reach the maximum timeframe of an E&M visit before you can add the extra 15 minutes. So let's take 99205 high-level new patient outpatient visit. That range of encounter time for the day is 74 minutes. And then you have to add another 15 minutes before you can report it. Well, I don't think many of us spend 90 minutes on a new patient evaluation. There are exceptions. There are academic programs that, let's say, are seeing complex motility patients, complex IBD patients doing initial consults, and they may be using the office outpatient codes for them. So there may well be use of prolonged service codes here. But it is not something that's easy for a GI practice to do. You need to exceed 54 plus 15 minutes before billing that code for a follow-up patient. So it's not something we do a lot of. But keep it in mind, there are codes for that. The code that we probably don't bill as much as we should are the prolonged service codes where the patient is not face-to-face with you, 99358. So keep in mind, this is for a given date. So let's say you have a complex patient, you're accumulating some medical records either before the visit or sometime later after the visit. If you just queue up all those records and review them on one day, if your work that day exceeds 30 minutes, you can be billing a unit of 99358 for that prolonged service patient is not face-to-face. If you do that kind of service when the patient is there, you may be able to then reach the 99417 prolonged service. But generally, we're not sitting there with the patient in front of us leafing through their complex medical records. So this is usually done on a day other than the encounter day of the visit. So there are codes for this. There's an additional 15-minute code, but I confess I've never spent that much time doing review of records all on one day. And that's really the limitation is that there's a single date restriction to this. Many of us will review some records on one day that comes from one source and review records on another day. Makes it hard if you're organized that way to build these codes. If you spend less than 30 minutes, you can't report this separately. And if you're doing a bunch of other services that involve time between visits, you may not be able to build this either. So if you're going to look into using this, look at the CPT directives about it. You can't be billing chronic care management, care plan management, some of these other things during the same time period as 99358. But a lot of times it's really our separate services. So visit prior to colonoscopy was briefly discussed earlier. And again, I'll just briefly touch on it. Since 2015, Department of Labor released some guidelines that were following up on the Affordable Care Act saying that patients don't have cost sharing when they see the gastroenterologist during a medically necessary visit prior to screening colonoscopy. So this applies to most commercial plans, but not some of the grandfathered self-insured plans or federal plans. And if you're working with HMO plans, Medicare Advantage plans, you have to find out whether this might be covered or might not be covered. But it allows for payment for these visits. Basically, if there's something that either the patient wants to just come in and discuss screening methods and what's involved, or there are some reasons to discuss it because of family history, et cetera. Some payers want the S0285 code. It's something that's not a traditional CPT code. It was invented by the blues. Some want to have you use the regular office visit codes. But keep in mind that Medicare doesn't say you can't see a patient before a screening colonoscopy. When there's medical necessity for a visit, that isn't because of the screening colonoscopy, but because of the medical conditions the patient has that are going to require you to take some special steps either for the preparation or other precautions related to the patient, then it is a reimbursable service, not under the Z code for screening, but under the medical conditions your patient is having the service for. If they have serious heart disease and they're going to need antibiotics or management of anticoagulants or insulin-dependent diabetics or on pumps, and they're going to need modification, et cetera, there are good reasons why some of these patients should be seen in a visit, even if they have no GI symptoms and that they're going to have a screening colonoscopy. So, I'm going to turn now to care management services because these codes have evolved greatly over the last several years. And if you just look quickly at the code series, it seems very confusing. I'll try to sort out the general structure of it and talk about a few codes that are applicable to GI practices, not without some work, some complexity, but nonetheless are feasible to do. And there are some new codes here that will make some of this even easier for us. CPT describes care management services as management and support provided by clinical staff under direction of a physician, which could be provided personally by the physician or their NPs and PAs. A patient could be at home or in a rest home or assisted living, but it involves setting up and But it involves setting up and revising, following a care plan, coordinating with other professionals and agencies, basically patients who have chronic conditions that are more complicated and really warrant management between visits. There are now three general categories of care management services, one of which not really very applicable to us. Chronic care management, there are a few codes there I'll briefly talk about. Complex chronic care management, these are very time consuming and involve essentially managing all of the patient's conditions and both the times they require, the complexity they require, really not for GI practices. But there are now four codes that are introduced this year with CPT category one for principal care management. And I'll go over what these are. And they really parallel the existing chronic care management codes. And a couple of them definitely are applicable for the GI practice. So it's really for specialty care, principal care management services address a single condition. So within these code structures, they're basically two codes for services provided by staff, the base and an additional 15 minute code, or provided by the physician themselves. And with an additional 15 minutes. So that's kind of the structure of the four code sets. And it's based on the time provided in a calendar month. And it cannot include time you spend doing other things during that month. So here's a traditional chronic care management service, 20 minutes or more of clinical staff time overseen by physician during a calendar month. And that really means general supervision. You don't have to be on the phone with the with the patient when your staff is doing some follow up or doing a video call or having an outside agency helping manage your patients with you and communicating with the patient during the month. But they're being monitored. But it requires the patient have two or more chronic conditions that will be long lasting. And that they that at least one of which has the patient at significant risk of death or exacerbation or functional decline. So these are not for trivial conditions, but many of our patients have serious diabetes, heart disease, other things, and GI conditions, or serious GI conditions like cirrhosis or not very stable IBD, and the patients are not very good about getting in touch with you when they need help. So these patients can get lost and easily decompensate when they're not being seen, and you're establishing a care plan for them. That's part of your basic E&M service. So the codes most commonly used is where clinical staff that's under your general supervision are doing this work 20 minutes or more, and if they spend an additional 20 minutes of time during a given month, they can be billing the extra code, or if the physician themselves are doing this service, they can be themselves billing these services. Now, that's not very common. If you think about it, nowadays, many of our patients, we could do remote visits to during a period between the routine scheduled things, but if they're paid like they are now, you probably get paid more for the equivalent of a 99213 than you would for these services, but if you can organize clinical staff either inside or outside your practice to do chronic care management, they can be separate services, separately billable. So again, getting back to the new codes, the principal care management codes, these are disease-specific management codes, and the patient may have multiple conditions, and maybe they do warrant more complex chronic care management, but if you are the one managing the principal condition that puts the patient at this kind of risk, then it doesn't need two or more conditions, really just one. So, you may have a Medicare patient with fairly severe cirrhosis who needs a lot of close monitoring, not all that good about taking their meds properly or their diet properly in and out of the hospital because of bursitis or otherwise just not doing well, encephalopathy-prone, or an older IBD patient on Medicare who's labile and having problems. It's not far out to think that these patients can benefit from being treated by your staff or by you. Again, physician codes for these, clinical staff for these, as applicable. So, it really has to do with team management between you and your staff, but again, similar language, but here it's a single complex chronic condition expected to last at least three months, so this doesn't mean a year or 10 years or until the patient's death, but it requires setting up and keeping track of a care plan, and here it's 30 minutes of physician time or 30 minutes of clinical staff time, a little different. Remember, chronic care management was 20 minutes or more of clinical staff time, here it's 30 minutes or more, but again, there are ways of building multiple units for these if you have very extensive principal care management. So, if you find this interesting, look through CPT, it's in the 2022 book with a lot of details about it. So again, four codes, these are the physician-directed services, first 30 minutes during a calendar month, each additional 30 minutes, and I believe here you do have to stick strictly by the 30 minutes, you don't reach the threshold by 15 minutes for either code, you have to have at least 30 minutes for billing either code, and these are the two codes for clinical staff time directed by a physician, 99426 or 427, this was the clinical staff time supervised by a physician. So, parallel codes, and it lays out the specifics, so these are things that I think we have been doing without thinking about it, without organizing it, without documenting it, but we should look at it and take credit. In CPT, there's a pretty good matrix that lays out which codes you use according to the duration of what you do, and so again, get familiar with those if you think they'll be applicable inside your practice, and payments for these codes are not insubstantial, and actually some of them have gone up for the coming year, the proposed payment for the clinical staff 20 minutes chronic care management up about $22 to $63, and some of the newer codes look like they will also pay at that same general rate. So, if you have clinical staff doing principal care management for you, 30 minutes of that kind of service you supervise could be paying $63 in a given month, any month that you carry out those services. So, those are definitely worth looking at. A few other things worth keeping in mind, because again, there are services we do, but sometimes forget to bill for, one of these are the code or codes for care plan oversight, and I'll give you a couple of clinical examples. If you manage home TPN patients who you're not seeing personally, except every so many months, you typically are doing a lot of work on their behalf, getting contacts from pharmacies, arranging lab, getting home health contacts, making care plan revisions, etc., and these are patients who are at home or in some sort of non-nursing facility, and you're doing the work, and it's generally your own physician work. You're not doing co-reporting of chronic care management, so you have to think about what service are you doing, but these are billable, and 99374 is really 15 to 29 minutes. So, if you do 15 or more minutes in a given month of that kind of work, and that's certainly going to be probably the minimum for any home TPN or complex home enteral fed patient, you can be billing for these services. Many GI services, GI physicians have one or more of such patients. So, patients on home management of TPN usually require some regular lab review, revision of orders, assessing their status through talking to family or home health personnel. Similarly, some of these complex enterally fed patients or patients getting complex medication therapies at home, but it's where you're not using chronic care management or doing sort of online exchanges with the patients themselves during that same billing period. Another set of services are home health certification and recertification. Again, patients who are kind of under our care, not the primary care physician, sometimes we're really the ones who have helped order the home health management and the home health agency send us the forms to review and sign, and Medicare wanted to encourage us to get involved in looking carefully whether these services were medically appropriate, making sure the right things are being done, noting what the progress reports are. So, the initial certification service for Medicare, G0180, and a recertification, G0179, and these are kind of routine things that are done in the course of a year, typically every 60 days or so, and your nurse practitioner or PA can be also doing this work and billing for those codes, and they reimburse pretty reasonably, $60 or better. So, they're worth thinking about. I want to spend just a couple of minutes talking about things that are evolving but probably not quite applicable to us. We've been seeing more and more remote electronic monitoring of patients, patients collecting data, whether it's from their Apple Watch or more sophisticated devices, some of which gets transmitted to physicians who look at it, and these are services that are going to evolve to become more applicable to GI patients. So, not only will there be just some data transmission and review, which we don't really do, but diabetologists may be getting a lot of glucose data from patients, and patients with severe CHF may be sending remote weight monitoring and other information, but more and more we'll be doing remote physiologic monitoring, including GI patients, and then increasingly doing therapeutic monitoring of patients who are hooked up to these kinds of devices. So, codes are evolving that maybe that we're not ready to use them, but they are now in CPT, and the concept is patients who are put on these monitorings, they can get a fee generated for the initial enrollment and getting them rigged up with the devices, and then a basic monthly management service of some kind, whether it's monitoring the physiologic data or actually therapeutically monitoring and handling changes in their care plans, and I'm not sure where these will overlap with some of the care plan management services, chronic care management, but they do exist. They're now new remote therapeutic monitoring, and this is right now set up for patients with respiratory or musculoskeletal conditions, but I expect there'll be some GI counterparts coming in the next few years where some of these codes may become applicable. For example, the company is developing some smart stoma pouches, which will help us monitor patients who often get in trouble. They have short bowel after big resections, and they very, very repeatedly get back in the hospital because of volume problems, electrolyte disorders. There are devices that will help us able to monitor and take care of these patients better. There'll be home testing patients will be able to do for bacterial overgrowth, home testing, fecal calprotectin for IBD to help monitor their care, so we'll be doing a lot more remote monitoring as time goes on, and at some point there will be ways to bill for those services that are not just part of face-to-face services. So what can we expect, though, for 2023? We've been living now for one year already, 2021, next year 2022, with the changes for E&M services in the office and outpatient. There's a large E&M work group of the CPT panel that has been overseeing this very big effort, taking input at every step of the way from specialty societies, so all of our GI societies have been heavily involved in these discussions, feedback, surveys. It's taken a lot of our time to try to help move these codes along and the changes to where they're sensible. So what do we foresee in the consultation codes? They probably will be all pretty comparable to what we need to do now in the office and outpatient. There won't be a level one. You'll require just a medically appropriate history and physical. You'll bill based on the days and counter time or medical decision making, and the medical decision making will probably be pretty much the same that you're getting used to now and probably retain the guidance that if the patient or family referred the evaluation, it's not a consultation. So a consultation is something where a professional asks you to evaluate something and it requires a written report back. So these are the changes I anticipate. These are still going through valuation. We don't know if these will wind up with good valuation relative to office and outpatient, and will these be applicable in the inpatient side? The same kind of structure, likely, but payer coverage, valuation still yet to be determined, and some of the nuances yet to be determined. Inpatient admission and follow-up will probably preserve the same levels that we've been dealing with, but otherwise the kind of requirements of documentation, the basis of billing using medical decision making, or the days and counter time will probably be the structure of these. It looks like inpatient and observation services will be merged into one code series, and the discharge services will probably remain largely as is, as will the same-day admit and discharge service. So we will see changes in these in 2023, yet to be finalized, so don't take this as gospel. None of this is. These are just what we believe is going to evolve, being worked over by CPT, being valued by the AMA RUC and the surveys to the specialty societies. And so all of this will probably not be announced until through Medicare, the proposed rule in July of 2022, and then finalized in the final rule of November or so 2022 next year, and starting to take effect in 2023. So we'll still be living with the current structure this next year, but the year after we expect things will change. There's still a lot of situations where guidance is awaited. Some of these decisions are yet to be made under discussion. Example, if you see the patient in the office and then you admit the same patient, will you be billing two separate services? What if you do an evaluation early in the day? Let's say you've admitted a patient in the middle of the night, and then you come back, see them later. How are you going to code that? Probably be through total time of the encounter day. What if you do a consult in observation? What code will you use? We don't know yet. If the service spans midnight, not sure how the guidance will be. Referral versus consultation, that's always been a bit problematic with consultations. What if you see a patient for the same problem versus a new problem? How do you use consult codes? All of these things are going to be clarified by the time the codes come out. So be paying attention. We'll be covering a lot of this in next year's course, I would expect. Then one more thing to talk about that may not come next year and maybe won't even come in 2024. There was a cheat code that was talked about and CMS and Congress basically put off implementing this until theoretically 2024. It's a cheat code used in conjunction with other E&M services to indicate the visits complex inherent to a more basic E&M service. Patients who have more complex medical needs, it would be an add-on code for the office or outpatient and maybe other settings, including telehealth. It looked like it was going to be valued at about $16. It was anticipated that 90% of primary care visits would actually be reporting this code because of the nature of primary care coordinating care for all of the patient's services, but it can be utilized in theory by specialists. It's actually a large part of why we expected the conversion factor to drop about 4% during 2021. Congress put that off. If this code does evolve, we could again be facing a significant budget of impact if this were to be implemented in 2024, which may further drop our basic codes, but with the thought that we would be reporting this in a significant number of our patients where we were doing complex care. It might not be for just say initial management of a GERD patient, but if it's somebody who's more complicated, not responding to therapy, getting other problems, or more complex patients to begin with, we may well be using these kinds of codes. Again, keep an eye out for discussions in the middle of next year, late next year, about whether there may be some further use of this code or it may get abandoned, but if it were to take place, it wouldn't be until 2024. I'm just trying to give you a sense of the future that may evolve. So I'll end here with another view of Death Valley. It's desolate in a way. It's beautiful in many ways, especially early in the day or late in the day when these amazing sand dune formations are there, but it's not a climate that easily nourishes those who try to live in it and our reimbursement situation is going to be somewhat problematic like that as time goes on. Has been for years for reasons I mentioned. So this is where we stand. I'll be happy to take questions as part of our Q&A session and I left my email here in case later there are other kinds of questions you have. So thank you very much.

medical billing

2023

revenue generation

underbilling

gastroenterology

tobacco cessation counseling

chronic care management