All right. Thank you very much. I admire all your resilience and hanging in there. It's been a long postprandial afternoon. We will have a break after this. And then later we'll be able to take questions at the end of the session about as much of everything as we can. So what I want to talk about are some things that we, again, we do a lot of, but we often forget to bill for, don't bill for right. And I want to clarify some of the rules around some of these things, because certainly are things that we should be getting recognition of. Again, my, there we go. The little arrows were. All right. This is from ancient Turkey. It was found in an old temple. And I believe the Egyptian or the Turkish writing here in the ancient tongue reads life is short, coding is long. So it was a fun thing. And I like to put that in some of my talks. So I mentioned some of the issues we're dealing with upcoming with the cuts in fees. If we don't have some act by Congress to change things. And of course, if you're not doing MIPS or meet the tighter MIPS requirements, the threshold is going to go up to, I believe, 70 or 75 points now. So threshold would be quite high. You don't get a lot of money if you get really, really good MIPS scores, but you get another 9% off if you fail MIPS. Speaking of that, incidentally, what Kristen was talking about with the risk adjustment codes, even though you may not be getting any direct benefit from Medicare Advantage plans yourself, if you're seeing patients through organizations that have Medicare Advantage contracts, they may not be giving you anything back just for the fact you report those diagnoses. Fact is your resource costs under MIPS are judged in part by the nature of the patients you're taking care of. So if you're not capturing some of those HCC codes she was talking about, which raises the average risk scores for your patients, then it looks to CMS when they analyze your resource costs that you're taking care of very low risk patients. And so you can actually gain something within the MIPS system on resource costs if you're billing some of those comorbidities. They don't have to be billed every visit, but once during a year, if you're taking care of patients with those high risks. And I showed this slide earlier, I won't dwell on it right now, but now we've been losing ground pretty steadily compared to inflation and things are not looking any better for the immediate future. So how you look at all this just depends on where you stand. An optimist tells you the glass is half full, the pessimist half empty, and the engineer tells you the glass is twice the size it needs to be according to Oscar Wilde. So we're going to see if we can fill up the glass some and maybe make the glass even a little bit bigger with some of what I call interstitial services, things that we really should be billing for because we do do them or things you can do a little differently so that you can bill for them. Nowadays, larger GI groups, and I think probably a lot of us in the audience today are from larger GI groups, we have more than just our professional fees as sources of revenue. In fact, in large groups, professional fees are now less than about 25% of the total revenues for many groups. And if you're a small practice that has almost nothing besides professional fees, then you're definitely facing hardships in the current environment. So lab and path, ambulatory endoscopy, facility ownership, anesthesia services, research, nutrition services, chronic care management, these are all things that help replace some other of the revenues that have fallen in professional fees because of the lack of increase in our conversion factors. So some of the things that we just don't think about often enough, I will spend some time talking about. I'll mention transitional care services, but you often get questions about these. I'll talk about things that you do sort of online using your portal and telephone, which are different than the telehealth face-to-face services, things you're often doing between visits. And I'll try to define what's billable and how and what that is worth. Chronic care management, I've mentioned already, and I'm not going to go into more detail now. And I mentioned home health and care plan oversight. So we won't spend extra time on those now. But again, there are other cash kinds of services that can be done within a service, within a practice. I mentioned some of these. In certain places, when you're doing a lot of open access patient care, you're actually doing a lot of service on behalf of that patient to get them set up for their procedure. I call it a medical evaluation that's done without a visit, rather than just, we need your forms filled out. It's a pre-procedure medical evaluation you're performing. And some practices, including mine in Pasadena, we've been able to apply an administrative fee that the patient pays. This is instead of a visit, we offer them to come in for a visit pre-procedure if they wish to. Most of them would rather not. And they know they face a copay and parking and driving and taking hours off from work, et cetera, et cetera. But we don't call it, we just need to get your forms filled out. It's a pre-procedure medical evaluation. The physician has to evaluate what all the information you submit. And that satisfies most patients about why we do this. Again, kits, supplements, breath tests that may not be covered by insurance, nutrition services, integrative health practices, or all other things that are professional fees that can be billed outside of insurance for the most part. But let's talk about transitional care. We do this a lot, and yet we often forget to do it the right way and be able to then get reimbursed about twice what a typical office visit would cost. There are two codes, 99495 and 96. When you're seeing a patient within a week or two weeks of a hospital discharge, and you're doing at least, you're doing high-level medical decision-making for that early visit, or at least moderate or high-level decision-making for one that may be going out into the second week after discharge. You can bill for a transitional care service, but you need to make sure that your staff has communicated with the patient or the caregiver in some fashion within two business days of the time of discharge. And then during a 30-day period of time, the sort of management of that patient is taken into account. The result, though, is that you have visits of typically about 40 minutes, 50 minutes, including all the things you do, and you can bill it on the day that you do see the patient then and follow up. And the fee you get is going to be about twice what you would have gotten if it was just billed as a standard office visit. So, if you see the patient within 14 days, then it might be moderate or high complexity. If you see the patient within seven days, again, these are typically high-complexity visits for the basis for the coding. But you've got to make sure your staff is aware that the patient is being told to have the appointment within seven days or 14 days, and they need to make that arrangement with the patient. They need to touch bases, make sure such things as did the patient, you know, get prescriptions for discharge, medications, you know, anything else falling through the cracks, and the visit then needs to get set up. So, I mean, typically when patients get discharged, we rely on the patient to call us, call my office for making an appointment. I need to see you within seven days or 14 days. Well, that's not going to cut it. You need to have your staff reach out and document, even if they don't reach the patient, at least document two tries over a couple of days. And then again, you can then qualify. And some medicine reconciliation needs to be part of the service you do, but that can be the date of the visit itself. All right, so transitional care services, we do a lot of. Keep in mind, though, for that, that only one physician can get paid for that. So, if your primary care group is set up to do a lot of these services, they may get unhappy with you if you do one before they do and you get your claim in first. So, if in your area transitional care is often done by other docs, you need to stake out what your territory is or what patients are appropriate for you. Series of slides I want to show comes from a talk that Patty Garcia from Stanford did, and I'm borrowing her slides here because they were nicely set up with good examples, just going over some of the non-face-to-face telephone and electronic services we provide. Remember that there are codes for telephone E&M. They only go out to as much as 30 minutes of medical discussion. The key rule here is that these should not be originating from a related service provided within the prior seven days or leading to an E&M service or procedure within the next day or soonest available appointment. All right, so that makes telephone services more of an incidental either pre-service work or post-service work to another encounter, but if it's a standalone visit and it may be sometimes explaining a complex test result that comes back or a new diagnosis based on the test that you ordered, but if it is not going to lead to another visit and that's beyond seven days, let's say a CAT scan that gets done a couple of weeks later, something pretty major comes up. You don't need the patient to come into the office, but you need a long discussion. You can be using telephone service codes and documenting them as a specific chart note or however you best document. It could be an addendum to the prior visit. It could be a separate standalone chart note. Currently under the public health epidemic, you can, emergency, you can be getting paid for these at virtually the same level as a face-to-face visit. That will not last, but it still applies right now. So an example of this, you see a patient for constipation, you advise on fiber and some Miralax generic, you schedule a visit months later, but months later, the patient calls said they've tried this or that, they're not getting better. You want to discuss the next steps. You can then talk to the patient long enough to document and be able to bill for a telephone service. If you spent the 15 minutes discussing these things and maybe some further tests and maybe a trial of a different drug, that can be a separate service. It's taking the place of the face-to-face service. So that's the concept of telephone service takes the place of what otherwise would have been a visit, doesn't lead immediately to a visit. It can then get billed separately. So coding during the public health emergency, same rules, but it can apply to a new patient. And again, this idea that you could do this with a new patient may disappear after the public health emergency and whether private payers are doing following the same rules now or continue after the PHE ends, you really need to keep a watch on what payers do either by watching their policies or seeing what happens to your billings. Mostly it's reported with a modifier 95 and the place of service where it would have taken place, which is typically the office and the payments that are being made now for those during the public health emergency are really the same payments. Okay. So as, as level two, three, and four office visits, and the time periods involved are kind of similar typical times and the public health emergency visits, the RVUs are similar. So we're hoping these will keep up, but we're not sure how well they will. We're lobbying hard to CMS, lobbying hard to Congress to try to maintain this as benefits. And they've sort of agreed for mental health services. And what we need to find out eventually by doing not, not asking, but doing is, well, how many of our patients that need telephone services have anxiety, depression, other mood disorders? Now, maybe that's not their GI symptom. Now that may not be the primary diagnosis, but they have mental health problems, especially during the pandemic. So I, I view telephone as very legit follow-up and especially our disadvantaged patients who can't do video calls because they just don't have the technology or the wherewithal to get it working. Another set of things we do a lot of, and often forget to bill for are what we refer to as online digital E&M, because we're not seeing the patient directly, but through some combination of portal messages, basically email that's, that's protected and or telephone services. That time that we spend ourselves, it may be anywhere from five minutes to 21 minutes or more for a period of up to seven days. The cumulative time during those seven days can be billed by one of these three codes, 99421 through 99423. And again, you try to create documentation that describes the bundle of things that you did. And the first portal exchange, you know, you may not know how much time you're going to spend. Patient may make an inquiry, and then you may make a quick answer. Then it turns into a series of things that may include some phone calls, ordering some lab, ordering prescription, something like that. At some point, you need to document what you've done and then submit a bill. So that could be, you know, putting in a task to your biller and just describe what you did, then at least you've documented it or create a little chart note or an addendum to the prior E&M visit. So there are ways to do this. So again, similar sort of a patient here, you've seen the patient for constipation, you've tried several things, you are going to do a follow up in three months. But a month later, they send you an email saying their portal message, it's not helping. And over the next several days, you have an exchange of information with the patient about other things to do. I get a lot of follow up portal messages, some of our patients just a very, very literal concrete, they just ask a lot of questions trying to clarify exactly what to do. Do I stop this ad? Should I take it in the morning? Take it at night? Can I take it with other medicines, things that I may not remember to tell them the first time through. But you know, once I've done something that's more than five minutes, I can bill for it if it's again, not leading immediately to another visit, and I've documented it. So these are things I do a lot of and I just test my biller with the information about what code to use and what diagnosis to put and then have some notation in my notes somewhere of what went on. So again, right now Medicare rules for this, you do need to be using a compliant platform that's basically your portal messaging, not just some outside email. So it needs to be essentially encrypted and safe, HIPAA compliant. It's for established patients only, okay, and it must be initiated by the patient. And that's typically what happens. So it's not something that you're sending a portal message to the patient about a test result and maybe have a little back and forth. But this is once per seven day period for cumulative time, starting with when you answer the first inquiry. Okay, so these are the rules. And these are the time periods. And again, at present, it's got a pretty decent payment. So it's not the same as a telephone service at those levels at the low level, but it gets up there if you're spending a lot of time on an exchange. Most of what I'll do will be in the 421 category, sometimes 422, if it's more complicated, and I have to do some other services on behalf of that patient. But it doesn't reach the point where I could be doing like care plan management, care plan oversight, or chronic care management on behalf of that patient. So there are a bunch of other services you cannot be reporting at the same time, kind of makes sense, you're really not using time and double dipping for the same kinds of service, though that's in CPT. So you can look that up. You should be aware of two other codes, even though right now, I don't think we use them very much. And these are the virtual check-in services. Medicare okayed these during COVID-19. But they've just published saying that these will be permanent part of Medicare. One of these is remote evaluation of recorded video or images submitted by an established patient, including interpretation with follow up with the patient. In other words, they send you information, you respond within 24 business hours, that usually means a few days or a couple of days into the following week, if you get the message on a Friday night. And again, it's not immediately coming from a prior visit or leading to a new visit. And the other is more of a virtual check in that could be by phone or it could be by email or, you know, again, an exchange that's similar to what I just talked about. But it has a separate G code. And that's for five to 10 minutes of the kind of medical discussion that may go on in that kind of an exchange. So what are some examples of this? You have a G-tube patient at home, then you see the patient, the G-tube looks good, you advise them what how to take care of it. And you want a photo from it in a couple of weeks, you get an image from the patient showing the skin is his heel looking good, you create a small note, you get back to the patient, and you know, tell them what to keep doing or do differently. And they can follow up as needed. Well, that sort of takes the place of a visit, but it's based on a visual image rather than patients sending you some status update by telephone or by by portal. Okay, I hate to tell you some of the images my patients would like to send me related to their bowel problems. I won't dwell on that. But again, a virtual check in that is more of a E&M equivalent, not based on video or image. Again, you're seeing that same constipation patient with hemorrhoid symptoms. A month later, they send you a message saying those things have improved. If you wind up spending five to 10 minutes between the portal exchanges and the documentation related to it, and you send them back a response, telling them what to keep doing or do differently and tell them what circumstances to be in touch with you again, that may warrant that brief check in or it may be for the 4421 video visit or telehealth, tele-e-visit, sorry. So again, Medicare rules, these are not considered telehealth, you don't use the modifier. The place of service is typically going to be the office where you do it, even if you're doing some of this stuff from home, where you would have done it had the patient been face to face would be the office. It's for established patients only. Again, it's not directly related to an office visit before or after. And you have those two codes to choose from. And you do need to have consent for the service somewhere in the middle of a record. But one consent can work for all of that. So you really can kind of include that within your global consents you obtain from the patients when they become patients of yours. They pay not a lot, a little bit. So they're not as good in many respects as the other services I mentioned, some of which though may not survive the public health emergency. Last set of these I want to go over a little bit are the e-consultations. Now consultation is between different professionals. And here we're talking about interprofessional telephone, internet, electronic health record assessment and management service. So the primary care doctor may send you kind of a consultation request with some information from the patient and just want your advice. And you're then responding with verbal or written report to the patient's treating physician. And these can be fairly short or it can be pretty long. Generally, when we're doing these, we're doing this in a fairly short way. And we may not be seeing the patient either ever or at least not for a while. You know, here's some tests to do if they turn out so and so. I think I need to see this patient. These are often done in remote rural settings. They're sometimes done in large university centers where specialties in sort of different departments basically do electronic consults. Please review records on this patient and advise about such and such. So these are handy codes to keep in mind if your work is organized that way with within large groups that may be in different offices, different practices. So a typical case might be a patient who's got poorly controlled diabetes with nausea, vomiting, and other GI issues, has been in the hospital a number of times, lives four hours away from you. So this is a very good kind of a patient where you may want to create a written record. After you've reviewed the primary physician's notes, you may be billing a 99451. And actually, the consulting physician can bill 99452 if they spend more than 15 minutes preparing the case for your review. So I like this graphic that Patty found for illustrating this. So again, Medicare rules do allow for us doing these things. But they're not going to occur if you see the patient within the next 14 days or have just seen the patient. So it's not really kind of follow up for a visit where the primary doctor reaches out to you and wants to understand something better. And you do have to have some documented written notes that go back to the referral source. It's for new or established patients. So you don't have to have a pre-existing relationship. And if you look at the fees for some of these shorter services, they're in the range of 2-1-1 or 2-1-2 or 3 type office visits when you get to the higher levels. So they don't pay a lot. But it's, again, work that sometimes we're doing that we don't get paid for at all. And comparing across the chart, again, you see right now telephone and video calls are at parity and extremely worthwhile to do. But coverage for this may well drop away. We're waiting to see what we can accomplish online digital. Probably we'll be here to stay. But we've got to watch the rules. And it pays reasonably enough to certainly spend your time doing some of that. And if these online digital things do fall away or the telephone services either get non-covered or covered at a very low level, we'll be using these virtual check-in service codes even though they don't pay very much and they're only limited to kind of 5 or 10 minutes per encounter. Still better than nothing. This chart just kind of expands some of those where it's easier to see side by side. So we hope we have good news on coverage later. And we are advocating very hard for permanently establishing more of these telehealth services that were approved during the pandemic and keep them going. Try to get coverage for audio, not just for mental health services. But right now, my interpretation of mental health services really covers a lot of our patients. CMS may come out with rules that just say, no, these can only be billed by psychiatrists, psychologists for certain types of services. But my view is right now, mental health services is what we spend a lot of time doing. So again, questions, please record them, put them in the Q&A. We will get to them as much as we can. And again, just remind you of things that are worth looking at if you need more education on coding. Our primer is still largely current. We don't have the new E&M guidelines in it. We hope to include that in a subsequent update. We will be publishing a GI coding update for 2022 that'll have a lot of information about what's new and changing. You'll see the site here, website here for the physician fee schedule lookup, which gives you your locality specific fees. Generally, these are populated sometime during January with the new fees for 2022. And if Congress acts, but not quite in time, you may see one set of fees come up in this area that gets changed later if we get some relief of the cuts. And then of course, look at the ASGE website for more practice support. Thank you very much. I also owe a lot of this talk to Edward Sun, who is real hot on these interprofessional consults, because at Stony Brook they do a lot of them. So if you have questions, please direct them to us. Thank you. That's it.

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