didn't see obesity or BMI listed for HOPD site of service for United. Is it not included? No, it's not. If you looked at those criteria, they do meet like ASA4 requirements. Morbid obesity constitutes an ASA3 status, but you would have to list any of the manifestations or the afflictions or anything caused by the morbid obesity. So, it's up to the providers. I mean, the list that I gave you from United is pretty well all inclusive. So, outside of that, it would definitely be up to your providers to state the added risks related to the patients in order to support the place of service hospital. The examples from my view would be, let's say, you state the patient is using CPAP for sleep apnea. Your ASC policy does not allow for doing endoscopy on patients with BMIs 45 and above, like mine. They have to go to the HOPD. That would be supportive, and if research somehow is denied, it gives you grounds for appeal. That's true. You have to know what your ASC policies are. I mean, as far as the diagnostics go, United also states that the hospital can be used if the technology that's required for that procedure is not in your ASC. So, that's also, a lot of it is based upon ASC policies. Okay, wonderful, and we do want to remind folks to use the Q&A function. We will be going through the questions in the Q&A function, and if we have time, we will go to the chat, but a lot of the questions do get lost in the chat, so we do ask that everyone use the Q&A function today. That would be most appreciated. Next question is, can you receive double credits for reviewing and interpretation of external records that also contain data such as EKG or previous endoscopy? That's a good question. You know, if you are summarizing those records, and then you're also doing a personal interpretation of one of their tests, I would give you credit for both, but you can't double dip. You can't use the same test to get credit for each of those components. It's not unusual. For instance, if I get a complete endoscopy report, color pictures, pathology, I may reinterpret what the patient was originally told, something about the degree of gastritis not being important, esophagitis assessment, does it really look like Barrett's or not like Barrett's? So, some of those things come up because the way PATH reports are described sometimes really is not clinically accurate or the way a provider may interpret an endoscopy finding may not be the same as mine, but I document that if something is changing. I'm just maybe noting, but I'm not taking any credit for what that documentation has to do with. I think the key there is making sure that you state my interpretation. Right. Yeah. Otherwise, it looks like you just read through the report. Right. Our next question is, counseling for obesity, diet, and weight loss, how do you maximize documentation for increasing medical decision making? I would probably build that by time. Time spent, because honestly, if it's a relatively stable issue, but you're spending a lot of time talking to the patient about their diet, their exercise regimen, weight loss tips, et cetera, that's all time. I would document that by time. And if you look at your CPT book, you look at each level of service that you bill out, each level has a range of time as a threshold. And so, document that in your assessment and plan. Document what you did, how you assess the patient, your recommendations, and then you can put a statement that says, I spent a total time of 45 minutes in the care of the patient today. Extensive time was spent discussing dietary counseling and management, all questions answered. But you have to have time documented if you want to build that level by time. And that's my recommendation. And I'm still seeing that wonderful little templated text that over 50% of my 30 minute visit was spent in counseling and coordination of care. That's really not valid anymore. So, I recommend that you guys get that out. And just like Kristen just said, it's the total time spent in the care of the patient that day. So, that means the time reviewing records before you see the patient, or even after, and the time with the patient, exam, history, counseling, et cetera, the time then afterwards with coordination of care and documentation, all of that encompasses your visit that day, just not the face-to-face time with the patient. So, I've been, when we do review of records and stuff, that's one of the things that I still see in a lot of practices, that they still have that blanket statement that over 50% was spent in discussion with the patient, but that's not the valid time component anymore. It's the total time. And depending on your EHR, that information may or may not wind up in the body of your note. For instance, in the EHR we use, the coding module allows you to put in the time in minutes specifically, which again, reflects the total day's work. And there's a text box you can jot down about notes of what you spent your time doing, especially if it's something outside the ordinary. And if you really spent unusual length of time for the conditions the patient was being seen for, you really do need to talk about what made the time unusual that day, which is usually something to do with counseling, coordination of care, explaining complex drugs, something of that nature that may allow it more advantageous to bill by time rather than by medical decision-making components. So, it's discoverable in an audit. I mean, the information's there. It doesn't necessarily need to clutter up the note you spend, you send to your referring provider, for example. So, our next question is, how much information should be documented in order to count review of external records? It just needs to be pertinent to the chief complaint in that visit. It's usually in a summary, but you don't have to put a dissertation of the entire note. It just needs to be pertinent. And just make sure that you just don't say I reviewed records, because otherwise we don't know if it's internal or external. And so, reviewed PCP, ER record, hospital record, Dr. So-and-so's record, et cetera. Just be specific as to who you reviewed and just a summation of what you looked at. I mean, obviously, if there's pertinent positives for certain tests, you want to bring them out, but you don't have to review everything that you looked at. You don't have to document everything that you looked at. For instance, so pertinent may be that patient failed this and that drug management or results of a particular test previously done. Doesn't need to be anything complicated just so that it's there and shows you reviewed it. And that's information you'll want to know for your future management of the patient. I know I had a question. I've been doing some training with the group this past week. And one of the questions by one of the docs was, well, I usually say I reviewed something under the past history. And where does it have to be in your record? And I said, well, technically there doesn't have to be a specific area. But if you put in the past history, I don't necessarily know if that is an internal record that you looked at or not. I would recommend that the pertinent test that you actually reviewed for this particular or ordered, et cetera, be in the HPI or actually ordering would be in your impression and plan. So as long as it's in the note that it's clear that this was not an internal review of records, then you get credit for it. Does over-the-counter medications like Miralax count as a prescription drug management if I prescribe it? In the eye of the beholder. Yeah, there are drugs that we can order as prescriptions. And I think there I'd be careful to be clear about instructions you gave the patient or the context that they were not doing well with other approaches. Therefore, prescribed Miralax with the specific doses and directions and maybe what to do if the first dose doesn't work. So you have enough description rather than just put Miralax. Right. I mean, technically, I mean, that is a very good question because there's a lot of PPI meds that are also over-the-counter strength. And so, you know, and Kristin had mentioned it earlier that says, you know, refill or continue PPI medication. I've basically been telling the providers to document, continue RX, put an RX in front of it in particular. If you're not doing a refill or you're not actually writing a prescription, there's not going to be a copy of a script going out in your record. All right. So as long as you're putting down, it could be a prescription strength dosage. As long as you put RX in front of it, I will count it towards prescription. And it's good if it shows up in your list of prescribed drugs, you know, in your medicine list rather than somewhere in the note that they're using it OTC. Mm-hmm. Correct. So our next question is, if I ordered labs and imaging on a previous visit, I reviewed those reports during this visit, does that count as data reviewed? So the AMA actually had kind of addressed this issue. And they said that if you order it at this encounter, it's to be expected to be reviewed at the follow-up encounter. So you're only going to get credit when you order it. But let's say you didn't see the patient, you didn't have a face-to-face, let's say they call or whatever, they call the office and you order something, then they come in to review those results. Then you get credit for reviewing. This is kind of hard, especially from an auditor's point of view. You know, if we have access to the practices EHR, you know, I can go in and I can look in the previous visit note to see if it was ordered to see really if I can give you credit for reviewing it or not. Otherwise, if it's just a standalone note, and I can't go back with that, this is kind of goes to that polling question. It could rely on the mood of the auditor as to whether or not they give you credit for the review of that test ordered. So the assumption is that this is a follow-up patient, an established patient, and you're reviewing labs or x-rays or anything like that, that, you know, the assumption probably for most auditors were you ordered it. All right, so you don't get credit for that. So I would recommend that you make a notation if you truly didn't order those tests, or actually they were ordered by the primary care or another consultant in particular, and now you're looking at them, make sure that you state that. The other way you can get some credit for it is let's say it's a patient who's calling you or sending you a portal message about some symptoms. You order some lab or imaging test, and then you get back to the patient about the results, and you may be giving some prescription or changing instructions. If that winds up more than five minutes of work, and you're not immediately about to see the patient in the office, you can then be using some of the e-visit codes as an example of what you can bill for. But you have to be documenting it, preferably in kind of a separate area of your chart, whether it's a separate little chart note, depends on your EHR, how the easiest way is to do it. And again, you need the time of all of that mentioned because you're billing based on time. So there you can get credit for that inter-visit service if it's not leading immediately to another visit. And our next question is, can we get credit for detailing physical exercise if detailed, if it's detailed separately from nutrition counseling? I'm not exactly sure of that. If you're talking about sort of prescribing exercise and giving patients some guidance about it, it's like diet counseling. So, you know, it would be time. I mean, in my fatty liver patients, I'll often spend time talking about what the goal of exercise is, what it accomplishes, how many minutes per week of different activities would be advised. So, I mean, that's, you know, it's similar to diet counseling. And so again, the total time of the visit includes that time. But you can just be stating in your note, discuss desired levels of exercise to promote metabolic improvement. You don't have to put a whole lot of detail, even if you give the patient a whole lot of detail, but you're putting down something about counseling the patient. And that did add time to your visit. So if it's documented that way, it's very plausible to an auditor that you spent some significant time doing that. Our next question is, for good documentation, time spent, does it require start and stop, or just time spent, is just putting time spent good enough, such as records reviewed 11am to 11.05am, patient time 11.12 to 11.30am. Those were the examples. Wow, that'd be great. No. Dr. Lindberg says no. No. Honestly, there is nothing out there that says you have to do a start and stop time. Now, if you are getting into where you're billing for prolonged care services, that's a different animal. But when we're talking about total time of the encounter, it's total time, we don't have to have start and stop time. Now I will say, I recommend you put like if most of your time was spent doing a particular activity, you should document that. But we don't necessarily have to have that start stop breakdown for each activity that you do. Yeah, we haven't seen any payers really discipline, penalize or anything like that. If it's not a defined breakdown between review and face to face and coordination and documentation yet, just yet, I'm not saying it won't happen. But as long as you're putting down your total time and let's put it this way, a summation of what you did that visit. So for this next question, I'm not sure if they sent it in while someone was talking and we need more clarity, but I'll ask it and you let me know if it's this person needs to kind of give a little more context here. They write do these rules apply to inpatient visits? Or do we still use the old rules? Is that too vague? Oh, no. Oh, good. All right, then that's just my not knowing. Okay, good. You're the experts. Yeah, unfortunately, you know, and we're hoping that these change and maybe Dr. Littenberg can kind of give us some insight later on. But we kind of have to have two hats going on. You got to have your office EM hat, you got to have your hospital EM hat. So yeah, you're back to the old guidelines. If you're billing any sort of, you know, observation inpatient, ER, even your consultations, and I know I didn't talk a lot about consultations and all that stuff. But there's so much to E&M that it's kind of can be overwhelming in one day. But if you're billing consultations to a pair that accepts consults, you know, not a lot do anymore. You're back to that old E&M documentation. So make sure when you are, I highly recommend going back to your templates in your office, if you have a consultation template, make sure that that's still prompting you for those elements. But if it's just you know, you're going to build just a new patient, then you're back, you're doing the current guidelines. Again, if hospital, you're back to the old hat. I think one of the things that we get asked about, you know, should we change our templates in the office to just reflect the new guidelines? You know, I think the question is, you know, our staff takes so much time taking the history and doing all that other stuff that we could actually see more patients if we don't have to document as much. And technically, we have the new guidelines, basically tell us that the level is not determined anymore at all by the history and the physical exam that you document. I mean, I'm not going to peddle, you know, the bean counting that we did to determine whether or not you met that level isn't as pertinent anymore. We still look to make sure that you did pertinent history and a pertinent exam related to the chief complaint. But what we really focus on is your HPI. That's still the important part of your visit and the impression in plan. And whether or not you change your template in the office depends upon if you're just still building consultation codes, you know, and also it's the mindset. I used to, I used to kid my doc about that, that he'd have such detail in his office notes. And then when we got to the hospital, there wasn't as much detail because we didn't, he didn't have the same template set up in the hospital. The hospital didn't have that same template. I said, what happens when you go to the hospital? He's like, well, I'm used to doing this way in the office and not as much in the hospital side. And I think it's like the mental template, you know, all of the stuff is important. Every provider has their own guidelines of what they want to ask. All right. And I think it goes back to that question that Kristen posted about, you know, some of the staff, the clinical staff decide, well, since it's not counting anymore, we don't have to do as much. No, not necessarily. I think you still have to base it upon what your, what your providers want to be done, you know, and to determine, I think on the initial visit, it probably still is important to gather a good amount of information on some of the follow-up care. There's a lot of detail that honestly, I don't think has ever been done. It sounds like, I mean, it's just, I can't say ever been done, but I questioned cranial nerve exams and everybody that walks through the door, you know, so it has to deal with the templates, et cetera, and whether or not you want to revise them, if you want to wait until everything now is across the board from the office to the inpatient side, it might be easier to do it at that point. Yeah, a lot, again, depends on how, what your EHR handles. So, I mean, our EHR has different templates for office and outpatient now rather than consult. You can set it up as consult when you want to, but there's still some areas where it's difficult, like if you're doing a consult by telehealth, we have a telehealth template and it really is following the office and outpatient new stuff rather than the old stuff. So, you just have to keep in mind that if you're doing a consult, you still need to stick by the old guidelines and have the appropriate documentation there where beams can be counted. I'll be talking later about what I expect for the rest of the E&M codes as things evolve, and so I'll save that for later. Our next question is, recent records, including labs, imaging, and recent PCP notes, were discussed with the patient and family. Does this count to show review of external records? Seeing a head shake from Dr. Littenberg, no? The recent PCP notes would count, but as far as the labs and imaging, we don't know were they from the PCP's notes, were they from the hospital, etc., but the PCP's note definitely does reflect an external. Yeah, I agree with that. I mean, there should be some mention of what detail was in there, if clinically pertinent, or to show that you reviewed the lab or reviewed an imaging test, which you'd just want medically, legally in your own record, or if you're going to make some decisions based on the information. So, it may be in the HPI, it may be something mentioned in the impression and plan, you know, recent CBC showed, you know, hemoglobin 10, therefore, we'll do such and such. When seeing stable IBD or cirrhosis patient, if you counsel on vaccination and schedule a screening colonoscopy or EGD, does it count as moderate risk 99214 visit? I guess it just depends on every, you know, the whole management of the patient. I mean, counseling on, you know, if it's a visit, to me, if it's a visit that's really just spent counseling and all that, again, you're back to, I'm back to recommending documenting time. Risk level, you know, you're probably going to have moderate for, I don't even know if you can have moderate, it may be a low level visit. Endoscopy workup, that's low risk, unless you have identified risk factors. Vaccination counseling, again, that to me is all like recommend time. This goes back to stable, and that little adjective drives me crazy. All right. Stable to me means completely asymptomatic. And I don't think sometimes that's what our docs and providers mean when they say stable. You know, if the patient is still symptomatic, but they're better than they were last time, that's not stable. All right. And even the AMA had to find that when they came out in March, and they said that the patient is still showing symptoms, they're still not at goal. It's still considered moderate complexity. Yeah, that's an extremely important guideline from AMA that I was very glad appeared last year in the new guidelines, because that is often just misconstrued. And it's best to term just kind of avoided when you can. So, you know, it can be IBD with, you know, continued symptoms of this or that, or continuing to need some medication adjustments, or cirrhosis compensated, but with, you know, continued ascites management needed, something of that nature. But if something about the status of the patient then makes the endoscopy high risk, you know, that changes it. You know, if they've got marked ascites, and you're needing to do an endoscopy for possible banding, that's a high risk patient undergoing potentially high risk procedure. Yeah, so that's really, I mean, that's kind of a question. You can't give a really good straight answer to. I mean, obviously, if they're stable, they're completely asymptomatic, labs are within normal, then that's considered low. That's a low complexity of presenting problem. All right. And if you're not looking at data into this at all, then most likely this is a level three. And our next question is, can you describe a little more about inter-visit phone call slash med prescription ordering test? What code to use, how to bill? Later. Later. Okay. So if you don't get the clarity you need later, you just put another question back in the box there. We have two questions in that are somewhat similar. So let me just read one of them. How to document minimal physical exam findings during a video visit? Does it matter for billing? And then another person who kind of said something along the same lines. I think they're stating telemedicine is considered an examination. So I think it's that whole idea of telemedicine physical exam. Yeah. I'm going to talk a little bit about this on my talk this afternoon for like cloning templates, what you should have in your notes. You got to review those audio video visits. You've got to look at those templates. We are seeing audio video visits that have physical exam elements in there that you cannot possibly do over the phone or over the video. I mean, so even the phone too, even the phone. Yeah. I mean, gosh, don't have it on your audio only visit, please. But we're seeing, you know, it should be general appearance of the patient. You should definitely have some sort of statement in your audio video. I'm talking about audio video that the patient appears well. They're not in any acute distress. You know, they don't have any obvious signs of jaundice or something like that. Keep it very general. I guess I would say you start talking about regular rate rhythm and, you know, things like that. It's like, OK, so you have to it has to make sense. But I would recommend if you're doing an A.V. visit, you should at least have some sort of a. You know, general appearance of the patient. I know I had I had a discussion with a provider because they were talking about cranial nerve examination was normal on an A.V. visit, I'm like, excuse me, you know, are you doing a complete cranial nerve exam on an A.V. visit? That's that's impossible. You know, so and why is it medically necessary on this patient? Well, it came down to that's our template. Yeah. You know, so yeah. And that's the thing. What we've seen with this pandemic and a lot of telehealth services being built is you're using the same template as the patient that comes in and sees you face to face, that you're palpating their abdomen. You're you know, you're listening. You're and so you have to the visit has to make sense. And I think, you know, Medicare came out and said that during the pandemic and these telehealth audio video visits, you're you can select your visit by medical decision making or total time. OK, so we again, we don't have to. We're not bean counting. So don't don't worry. Don't don't worry about do I have eight organ system exam here? Worry about what's pertinent and assessment and plan your chief complaint, your HPI, your assessment and plan has got to be very clear, very specific. That's what you should focus on. Yeah, that that guideline came out really before the 2021 codes were launched in like April of 2020, when the pandemic started. So the main place you can get bagged on your physical exam is if you're trying to do a telehealth consultation, especially a new patient. Right. You need a certain level of exam. Probably aren't going to get there by telehealth unless you really put put some very weird language in and have the patient do some odd things on online video, video, video, palpate their own abdomen and tender, you know, make it make, you know, I've seen patients about whether they appear short of breath. You know, are they coughing and clearing their throat? You know, you can document a lot of stuff you can see online. I mean, I've documented herpes zoster as a new problem with an abdominal rash because patient was very good about showing me the rash. So you can do stuff and then the document, but your templates can get you in trouble, obviously, easily there. But we don't do a lot of consultation visits, much less by telehealth. So that's not going to bag you very often.

documentation

billing

medical visits

office setting

hospital setting

E&M guidelines

patient counseling