So I'm going to talk about some of the other E&M related things that we often do and sometimes we bill for but we often forget that we can bill for them or how to bill for them what some of the criteria are. I use some of the illustrations that Patti Garcia put together for a talk from a couple of years ago because they were so expert, but I'll start with a couple of polling questions. So polling question number one, in recent years, the percent of visits billed at level five for GI is comparable to other medical subspecialties. Is that true or is that false? Remember we referred to the number of level fives for GI seeming to be a lot lower than it used to be years ago. Well, how are we compared to other medical specialties? What do you think? All right. So there was a split here, but the predominant answer was false. And in fact, the number of level five GIs are a fair bit lower than many other medical subspecialties. So indeed, we seem to be under coding in GI. This was using data just a couple of years old. So I think we still have problems and the changes in EM documentation, I think really should allow us to capture our level five work better. The next question is somewhat comparable. In recent years, the percent of such complex new patients in GI in your practice. So this is, you know, there's no right answer here. I'd like you to estimate what you think you're doing and, you know, providers or billers, you know what, what you think you actually are doing. I'm just interested in your, you know, how, how we seem to split right now. Okay, well, that's interesting. So we think we're seeing a lot more complex patients than we've seen to be billing in the last couple of years. So that says you have homework to do. That says you need to go back and review the level four, level five distinctions with your providers need to see if documentation holds that you can be and should be billing the level fives. And it makes a huge difference in ultimate reimbursement for your practice. So it's an important thing. So there you have some homework to do. So as I keep reminding people, life is short, coding is long, that this was from an Egyptian tomb long ago. But I think this states it well, there's a jug of wine on the left side there. And I mentioned before that top priority economically for practice gastroenterology is the lack of Medicare updates and much of what's probably wrong with current medicine, how hard we're having to work, how many patients we're trying to fit in, how many procedures we're trying to do. Looking for all kinds of ancillary services, really reflects this tremendous lag. You can see physician updates have been virtually flat since 2001. The little up bump here, reflected Congress, which now is trying to take it away because it was temporary. And practice costs, as you see, have gone up probably 30 to 40%, 40% or more consumer price index, more than that. And yet the outpatient hospital updates have gone up quite a bit steadily above general rate of inflation. So we're looking for changes where we're advocating very hard to try to make things better. We are trying most specifically right now to avoid the four and a half percent cut in the conversion factor, but also the sequester, which is going to be four percent, which is trying to do budget balancing on our backs. So we're trying to achieve a lot of things and remains to be seen what we can accomplish with Congress this year. But then, as I said, we have a long term agenda. And so, you know, we were up at a $36 conversion factor, which fell and is potentially going down to $3,306 if things go badly for us, 26 years of losing ground, if you go back even to 1998. So we'll see. And I also remind us of the quote, to keep some optimism here, the optimist will tell 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. A lot of stuff we're trying to deal with and we can't solve it just within our own practices. What I'll talk about here are things that we often do or forget about or we don't bother to bill. And a lot of people, when I give coding talks in my own practice, I hear back from my providers. I never knew we could do that. Now, the typical larger GI group, which most of us are in, has many revenue sources. And in fact, the professional fee part of the overall GI reimbursement has been decreasing in absolute and relative terms, replaced to some degree by lab and path. If you have that in your group, many of us have some degree of interest in an ambulatory endoscopy facility, but many of us are hospital based and we don't get any of these ancillary services. Some have built out anesthesia services using CRNAs. Many practices have research, nutrition services, chronic care management, supplement sales, prescribing, etc. But the core of what we do is still E&M services and the procedures that are based on them. So I'll talk here about what I'd call things coming out of the Center for Forgotten Information, transitional care services, some of the portal and telephone services, different than telehealth. OK, things that we're doing online. I've already mentioned chronic care management. I won't deal with those again. Home health care plan oversight touched on those in the other talk. But there are also other things that practices are sometimes doing. Some are using an admin fee for processing open access patients. If we're foregoing a visit in the office, which theoretically we could do for commercial patients and sometimes should do and want to do for Medicare, but can't always, doesn't mean necessarily that you couldn't charge some admin fee for this. Some areas, this is quite justifiable and practical. Other areas may not be due to competitive forces selling prep kits, supplements, breath tests, which some payers really don't cover and yet can be helpful for helping to diagnose patients with IBS as having a form of bacterial overgrowth, nutrition services, which, as mentioned earlier, basically it's a cash pay service. And there's some groups that are doing what I call integrative health practices. But let's talk about some specific CPT codes. I'm reminding you of transitional care management services. These are basically patients who are being discharged from the hospital or occasionally a SNF and who can and should be seen within a fairly short timeframe after the service, after the hospital stay is done. And there are two codes. One is requiring a face to face visit within seven days, nine nine four nine six. And the other, not quite so urgent, within 14 days, nine nine four nine five, requires comparable levels of medical decision making. So the face to face visit needs to be complex. These are patients who are sick and have complex needs. That's why they need to be seen soon. And they tend to have high requirements of medical decision making, but they can be based on time. Also, medical decision making of moderate complexity here. A key thing that we fall down on and one of the reasons we can't do this very commonly is because we fail to communicate with the patient within a couple of business days of the discharge. And this could be a phone call, an email exchange or some kind of face to face with the patient or caregiver within a couple of days. This is basically a staff service. But look at the RVUs involved, 2.78, 3.79. So these can pay $230 to $310 for what's typically a 40 minute or 50 minute intra service time. And this is a 30 day bundle of service from when the patient leaves the hospital. But many of us just are not set up to do that, even though we should. You know, when we see a patient who really should be seen in that time frame, the point is to communicate with our staff, to contact the patient, not wanting to set up the visit, but to do a couple of other things and make sure that then it's followed by the face to face service within the seven or 14 day time frame. And again, these are patients who really do typically have at least a moderate level of complexity in the decision making. So you need that interactive contact. The face to face visit needs to be done within a two day time frame or at least document you tried a couple of times. So it requires a health care provider just seeing the patient in the hospital to notify the staff to make the contact. And maybe it won't be the same doctor seeing the patient and follow up, it doesn't have to be. But keep in mind that for this service, though, the first doctor to build this is the doctor who gets paid. So there are some primary care practices that seem to be extremely good at setting up transitional care services, coordinating with the hospitalists and it's first in first served. So if it's a specialty patient, though, we should be able to take advantage of that. So I think we're well aware that we have the ability to bill for telephone services right now and under Medicare, these are feasible to be doing and getting reimbursed for. And that wasn't the case some years ago. And it's not clear what will happen after the public health emergency ends, but it's quite possible this may go away. And I'm not talking a telehealth visit, I'm talking here purely a telephone E&M service. There are three levels, five to ten minutes, up to twenty one to thirty minutes of medical discussion. That's what the service is. And it's provided by a physician or nurse practitioner or PA who can report services to an established patient. So it's not a new patient and it's not originating from a related E&M service provided within the previous seven days, nor does it lead to an E&M service or procedure in the next twenty four hours or soonest available appointment. So this is basically a standalone service. This is, in effect, a substitute for actually doing some kind of face to face telehealth service or setting up a procedure. So you may talk to the patient who contacts you and decide, oh, you need an endoscopy. We'll get it set up as soon as we can. And that would not allow separate billing for a telephone management. But there are a lot of times that patients contact us, you know, I may have seen them six months ago. Now they're having a flare of their IBS or their dyspepsia, their GERD. And they contact us, leave me a message. I'm having a problem. What should I do? And I can have anywhere from a five to sometimes 10, 15 minute discussion with patients. I may throw in a couple of ancillary things like send in a prescription or order some tests. But basically, the key service is a telephone service. And if I really don't remember to be billing for it, how am I going to get paid for that work? A lot of these will be after hours or weekends when you're on call. And so it may not be all that convenient to document. But at some point, you've got to put something in the chart and you've got to let your biller know that something was done. So here is kind of a typical kind of a situation. You might see a patient for constipation and advise on some fiber and other management and say, why don't you come back in six months? But they call you a month later and they're really not better and they want to know what to do. So you either just spontaneously or schedule a telephone visit encounter to spend a while discussing things, maybe switch their drug. But you can create a brief note then afterwards to document what you did. Different EHRs handle this differently. Sometimes you just add an addendum to a prior visit. Sometimes you can put a little separate chart note or even just document something alongside the task note that you were sent. And if it was this lengthy visit, then you can be doing a nine nine four four two. So there are Medicare rules now during the public health emergency where you can do this for new patients that will probably go away eventually. But right now you can. But the basic rule is still the same. It's in effect a service that doesn't lead to a different face to face or formal telehealth visit. And it must be patient initiated. OK, so when you're getting the path report back, maybe a week later from your scope and you call the patient to tell them about the result, that is not a telephone service that you can bill for. OK, that's the follow up, that's sort of the post service work for the endoscopy or colonoscopy. And then there are rules about how you report this. The place of service where the visit would have taken place, so it's usually an office place of service with a ninety five modifier. And these are not trivial. The phone services can really earn a considerable amount of time because the RVUs for these are pretty non good compared to other office services or comparable somewhere in the level two to level three range or even level four in the unusually lengthy conversation. I had a similar I had a service at this level yesterday. I was trying to reach the patient about their liver disease problems and the need for a liver biopsy and what may follow if they have autoimmune hepatitis. And that was a twenty five minute discussion. And I still had to put in some orders and do some other things. So had I been forgetting this, I would have been losing a fair amount of money on this. So these are important services to utilize and make sure they're being documented and being billed. The other group of services, which is rather similar, and again, liberalized during the public health emergency is the online digital E&M. There are three codes here, which are basically the descriptor online digital evaluation and management service for an established patient for up to seven days, cumulative time during the seven days, of five to 10 minutes, 11 to 20 or 21 or more minutes. So the rules are kind of similar. The basic notion is they don't lead to an immediate visit or follow an immediate visit. This isn't the follow through or a preliminary to another service. This has to be standalone. So again, in this situation, let's say you have that same constipation patient. They've now had their switched drugs and you're gonna see them back in three months, but patient calls sends you a portal message a month later saying, not helping, I'm still not doing well or having too much diarrhea from an act of tide. And over a couple of portal exchanges, you've spent a total of seven minutes trading messages, discussing what to do. Maybe they try something and a few days later, they say they're still having some issues and you may schedule a visit maybe a while later, a month later, you create a brief note, you've spent 12 minutes doing something. And so you can bill 99422. This is a series of portal exchanges. How often do we do these and just sort of forget about it? This happens not infrequently. And again, some little note as an addendum to your prior visit is easiest or some other little chart note. But again, you have to notify your biller that you did this, what code, what diagnosis and good billers will check the documentation to make sure it was actually done. So these rules do require a HIPAA compliant platform, not a HIPAA complaint platform, compliant platform. It's for established patients only, must be patient initiated, can't follow a related E&M visit and record only once per seven day period of cumulative time. So there are situations where you may be doing this with patients repeatedly between their visits, depending on what you want them to do and what they think they need from you. And that's okay. It doesn't pay all that well compared to telephone management. So sometimes when I know I'm gonna have to spend a while talking to the patient, I get a portal inquiry. I may turn that into a telephone service knowing that it will pay significantly better. On the other hand, I can rather quickly do responses through the portal to simple inquiries, even if it may wind up with a series of little quick portal exchanges. The key is documenting it, remember you did it, let your biller know, take credit for the work you do. So it doesn't, you know, you need to just make sure these things don't overlap with other chronic care management or other E&M services. So there are a lot of exclusions in the CPT book. And if you're really not familiar with using those, get familiar with them. There are a couple of other changes that look like they will be permanent, the virtual check-ins, G-codes that CMS created. One is remote evaluation of recorded video or images submitted by an established patient, including interpretation with follow-up with the patient within 24 hours. And again, this isn't just something that came right after a visit or later. Now, in GI, of course, some of the things patients forward us in images are not too exciting to look at. I've certainly have had patients send me examples of what their rectal bleeding looked like. But once in a while, I get something interesting like a rash and can diagnose zoster without the face-to-face. And, you know, sometimes they'll forward me images of who knows, some lab and other things that I need to look at. And that's okay. There is a code bill for it. You gotta get back to the patient within a short time. The other is a little confusing, G2012, because it's a brief communication-based service, which is like an E&M. It's like a five-minute phone call or a brief portal exchange. It's five to 10 minutes of medical discussion. Again, it's separate, distinct from preceding or immediately following up on E&M services. And this was really kind of one of the first telephone-based services that CMS allowed for. And it's referred to as a virtual check-in. The problem is it turns out to not reimburse very well compared to the telephone services. So if we continue to maintain payment for telephone services, this will be useful. So here's an example of a G2010 clinical case. You see a patient for inflammation around the PEG site, doesn't look infected. You advise on a barrier cream. You ask them to send you a photo in a few weeks. You get an image from the patient showing things look good. You review the image. You may let the patient know by portal or by phone or even by staff that the site looks good and they can follow up as needed. You create a brief note for the date of service, the image interpretation, and can build the G code and get paid a little bit for it. So these things do exist. The virtual check-in, again, kind of a similar scenario, maybe a patient with constipation and hemorrhoids, you advise them. A month later, a patient says they've improved because you asked them to follow up and let you know how they did. You respond, telling them what to continue doing, keep up their fiber, maybe their needed PEG solution, and they don't need to come back for X period of time or PRN. Again, you create a brief note, describe the medical decision-making in effect. Patient is doing well with their fiber and they're no longer having hemorrhoid symptoms, doesn't need any further procedure or visit just now, and you can build the G2012 code. Okay, so it's not considered telehealth, so you don't use the 95. You do report the place of service where it was provided typically from your office, only for established patients, separate from E&M services immediately preceding or following. And the two codes for images or technology-based brief communication, telephone, portal, email, whatever works. There should be some indication, at least annually, that the patient agrees to have you do those kinds of services, and this can often just be incorporated in the general consents you have for the practice. So the problem is, though, that this five to 10-minute virtual pays only $15, a small RVU compared to a five or 10-minute telephone conversation. So at least during the PHE, and for about 150 days after the PHE ends, which may be sometime during 2023, or it might get extended, the telephone service certainly seems to be the preferable way to deal with these things. There was a question earlier about the interprofessional telephone consultation codes, and if you do a lot of these within a group practice where primary care docs and others consult you electronically about patients who you share a medical record, that this can be a worthwhile thing to do. This is basically a service provided by the consultative physician. It includes a verbal and written report back to the patient's treating or requesting physician or other qualified QHP. But there are code levels of only five to 10 minutes of this medical consultation discussion and review going up to over 30 minutes. So because these don't pay terribly well, you should carefully consider whether this is appropriate or trying to set up something more substantial with the patient involved. But this does not require the patient direct interaction. This is something that's done with a consultative physician answering a question from the referring physician. I've got this patient with such and such labs or imaging. What do you think my workup should be? Or do you think you ought to see this patient and how urgent is it? That kind of thing. But if it warrants five to 10 minutes of discussion and review, okay, then you can be billing for that kind of a service. So you're able to get access to the chart to review, which is getting increasingly easy even if you're not in the same practice group these days. Many of the epic level systems and some of the others that use some of the interchangeable records more easily, this is getting more feasible. So a typical e-consult clinical case. So you may have a patient with poorly controlled diabetes, nausea, vomiting, constipation, but lives far away. The local PCP wants a GI consult, make sure the workup and management are appropriate so they can transmit to you a bunch of records that you have to review, description of the case and what questions they have. And you might then create a brief written report documenting that and you have to have some kind of verbal exchange or written exchange back. But if you spent more than 15 minutes on the case, you can bill a 99452 for that service. So for Medicare rules, this does apply, but again, you can't report it when a face-to-face encounter occurs in the prior or next 14 days. But a lot of times we can't see patients that quickly. You need to have the request for the consult documented in the patient's record that's on the sending end, the place of service, and it can be for new or established patients. So at least again, under the current emergency situation, these are feasible. And the 451 note where you need to have a discussion with the referral source, $38, if it's just a brief written response to some record review and it takes five to 10 minutes to do, 18 ranging up to $74. So it's reasonable under the right circumstance. And it's something I think we'll be doing more of increasingly as we get more interconnected, especially if we're so busy, we really can't see patients in a reasonable timeframe. So I'm not gonna spend time on this chart, but it arrays all of these services we talked about, gives you the codes, gives you some of the most current, well, this says 2020 payment. Some of these are updated to 2021, but not updated yet to 2023. But you get an idea of the order of magnitude. And clearly the telephone service is preferable to these other services where it's applicable and where you have time to spend that kind of time in one session talking to the patient. Keep in mind too, there are a lot of us who could set up a telehealth visit rather easily, even on an evening or a weekend, sending out text messages to the patient. Hey, I wanna do a telehealth visit with you in response to your portal message. Look for my text and click on it and we'll get a telehealth visit together, either now or at certain time during the evening or during the weekend. And then you can just do a formal visit for telehealth and bill it accordingly. So again, keep in mind the flexibility we have of our systems now and how you can take advantage. We are pressing very hard to permanently establish a lot of these telehealth services, expanded services that were approved during the pandemic to continue beyond the end of the PHE. And we're continuing to press hard for payment parity for video and audio only services with the in-person E&M. Unfortunately, CMS seems to be saying that the audio only are not gonna be able to continue past the time of the PHE. And you think about the patients who have poor healthcare access, and based on poverty, rural situation, et cetera, they're the ones who typically lose a lot of the ability to do telehealth visits. So this is gonna be problematic. So that's what we have uncertainty about, but keep in mind after the PHE is declared over, Medicare says for 150 days, there will be no change. We now know the PHE is going into Q1 of next year, maybe Q2, and we don't know whether the flu and the RSV and all that will make this even more prolonged or because there's poor uptake of vaccines, there will be another surge or two of COVID early into next year. So remains to be seen when the PHE will really be over. And we'll see. There will be some exceptions for mental health. So keep an eye on that because after all, who is not stressed out these days? And we also are seeing lots of patients with post-COVID conditions that are whole variety of things. And many of these involve depression, brain fog, et cetera, et cetera. So we may be able to extend some of our liberal policies when mental health issues are involved. The rules will be written and we'll be right there to let you know. Resources are available. We will be doing another coding update from the Tri-Societies coming out early in 2023. I put here the place to look up the physician fee schedule, which will be updated soon with 2023 fees. And you can look at your own locality fees and update your own systems. So I thank you and happy to take questions during our Q&A upcoming.

E&M

gastroenterology

underbilling

EM documentation

transitional care management

telephone services

reimbursement