So, everything we just went through, we're going to kind of put them into play, okay, so what would be more kind of a level three or four or five, whatever, okay. So again, contact information, disclosure, all right, so let's take the first patient and remember we're talking about office right now, established patient, IBS, so patient comes in with IBS, it appears under control at this time, continue current dose and frequency of amnesia, return in three months for reevaluation, unless otherwise indicated, okay, all right, so taking that table that we just went over, what level do you think this would be? We've got one stable chronic condition of IBS, we had no data, and we gave the patient their prescription, all right, so look at this table, remember, two of the three, well, we don't have two in the same column, so what do we do? We have a low, we have a minimal, we have a moderate, you pick the one in the middle, okay, so overall decision making for this patient is low, 99213. Now let's take another patient with the same condition, IBS, it appears under control at this time, despite increased stress factors, increased anxiety due to increased financial and work stress, continue medications for IBS, increase amniotryptoline, she's requesting psych counseling and I believe that this would be beneficial for her, appointment was made with Dr. X next week, return in three months for evaluation, unless otherwise indicated, all right, so we're dealing with a chronic condition with side effects, so we got moderate, minimal, for data, there was no data, we still have a prescription, so we have two moderates, this is a level four, all right, so the first one, IBS, it's stable, doing well, et cetera, good to go, level three, this one is a level four. So if you think about this, you're not gonna bill a ton of level twos, because that's minimal, so with the new guidelines, it allows a lot of those level twos to become level threes, level threes to become level fours, but hard to get a five. Here's a new patient, left upper quadrant pain, history of an ulcer, onomeprazole per primary care with no improvement, left lower quadrant abdominal pain has been treated for diverticulitis with no change, ventral gives the patient some relief, no evidence of diverticulitis on CT scan, but showed a stone, renal stone, reviewed primary care's records and hospital records, details were in the HPI, nausea with early satiety and indigestion, so continue current medications, follow up with PCP regarding renal stone, left side pain, gastric emptying scan, follow up in a month. So this is an undiagnosed problem with uncertain prognosis, we do not know what the pain is, we're doing our own workup, we also have moderate for data, CT scan was reviewed, we ordered a scan and we reviewed records and prescriptions, so we have moderate all the way across the board, this would be a level four. All right, new patient, chief complaint, diarrhea, all right, so 82-year-old female with diarrhea for the last six months, she's new to our practice, she has up to five loose bowel movements per day, diurnal and nocturnal, watery type, associated with mild abdominal cramping, not associated with fever, GI bleeding, significant weight loss, per patient she took antibiotics for a week, two months ago due to an upper respiratory infection, she denies any recent travel or other family members with similar symptoms, she drinks coffee daily, review of previous colonoscopy just showed diverticulosis, diarrhea, impression, persistent diarrhea for the last six months, she had a sister with colon cancer, she has indications for colonoscopy, if lymphocytic colitis is proven on biopsies, then intercourt will be started, it is necessary to rule out C. diff and or celiac disease, so we've got a workup, colonoscopy, check celiac panel, stool for C. diff, encourage hydration, avoid caffeine. So again, we're dealing with an undiagnosed problem, moderate, external records and ordered our own tests, that's moderate. Diagnostic colonoscopy is low, because it's considered what we didn't say was a major surgery for the patient, we didn't document any risk factors specific to that patient, so the assumption is low, because nothing was documented for risk. But we still have two moderates in the first two columns, so it's still going to be a level four. All right, here's another new patient, acid reflux. So 54-year-old male referred by Dr. X has a history of duodenal ulcers 15 years ago, has had new reflux symptoms in the past year and is on protonics. Recently they have flared, denies any dysphagia, never smoked, rarely drinks, impression, symptomatic GERD. EGD to rule out Barrett's, patient verbalizes understanding the procedure. All right, so this is a level three. We've got a moderate for problem, but we had no data and there were no risk factors documented. Okay, so that's a level three. All right, so I'm going to, I threw in an initial hospital visit and a hospital follow-up visit, because the guidelines, and again, Dr. Littenberg is going to go into this this afternoon, but the guidelines are kind of mirroring the office as far as the decision-making table. They just included a couple more options for a hospital-type patient, but everything else is the same that we just went over. Okay, they didn't take anything out of that table that we just addressed for the inpatient side of things. So I'm just going to give you kind of a little light for when we go over them in detail. So initial hospital visit, GI bleed, acute blood loss anemia, we've got a 46-year-old male admitted with blood and stool and significant anemia on labs 9.5, he has a history of peptic ulcer disease and incent use, takes ibuprofen daily for chronic pain, he described blood as dark, no pain with bowel movements, the bleeding started yesterday, and since then he feels very weak and fatigued. He denies any fever, weight loss, or pain, we've got a past medical history of ulcer disease, chronic back pain, otherwise healthy, no family history, and drinks socially, no tobacco. We've got a constitutional, appears weak, pale, no acute distress, he showed slight hypotension and elevated heart rate on vitals, GI exam, bowel sounds active, no rebound or tenderness, cardiovascular, tachycardia noted, no murmur, lungs clear bilaterally, skin appears warm and pink. Impression, 47-year-old male with a distant history of peptic ulcer disease admitted with significant blood and stool and acute blood loss anemia, he was noted to have mild hypotension on exam, he does admit to daily inset use from chronic pain. Plan for urgent EGD to look for source of bleeding, given his history of chronic inset use, monitor hemoglobin closely and transfuse if there's a significant drop, I will start the patient on an IV PPI. Patient has significantly higher risk for this procedure due to chronic inset use and history of peptic ulcer disease. Alright, this is a 99222 admit. So you notice, we didn't bean count the history and exam. We don't need to starting January 1st. It's going to be pertinent to the chief complaint, right? So this is an acute illness that poses a threat to life or bodily function, that's high. But we reviewed a hemoglobin, so it's minimal, and minor surgery with risk factors, moderate, so 99222. Here's the follow-up, hospital follow-up, chief complaint, GI bleed, acute blood loss anemia, status post-EGD, okay? So this is the follow-up the next day. Patient is doing well, he had an EGD yesterday, which showed an active bleeding gastric ulcer, which was treated with epinephrine injection, his hemoglobin increased to 10.5, so transfusion was not given. He feels better, more energy, no longer passing blood. We've got objective, just constitutional, and GI. Impression, patient presented to the hospital initially with blood in the stool, which is resolved. We performed an emergency EGD yesterday, which showed an active bleeding ulcer, which was treated, doing well and stable. Continue to monitor hemoglobin, continue IV PPI therapy. If he continues to do well, may be discharged tomorrow. Counsel the patient on inset use and ulcer risks. All questions were answered. All right, so we've got a stable issue. We had a review of hemoglobin again, and we still have moderate risk because the patient is still on that PPI, but we have minimal and low, okay? Minimal and low, if you look at the new definition for 99231, it's overall straightforward or low medical decision-making, okay? So there's only three levels of follow-ups in the hospital. There's not five. So we've got level one, level two, level three. So that's just a little insight into those new documentation guidelines. All right, so question. When billing by time, time spent by clinical staff can be counted for the level of service I bill, true or false? 23% said true, 77% said false. It is false. Unfortunately, we cannot count, and that was specific in AMA, is we cannot count the time spent by your clinical staff. It's provider-patient time, provider, total time of the patient encounter by the provider, which takes me to time billing in the office, okay? So again, we've got this slide in here that reminds you. It's face-to-face time. It's non-face-to-face time. And what types of activities can we count towards medical decision-making? And that definition by the AMA of time spent. And there's your time thresholds again to remind you. All right, so here's an example, clinical example for time. Established patient of the practice was on vacation in Florida and experienced severe symptoms and flare of her ulcerative pancolitis, which prompted her to present to the ER hospital in Florida. She was admitted for a four-day stay until her symptoms improved and patient returned, was instructed to follow up with her GI as soon as she returns home. So patient was seen by her GI doctor the next week. Doc spent 15 minutes on the day of the visit reviewing hospital records from Florida. Another 20 obtaining history and exam. The physician decided to move her Remicade infusions up to six weeks from the eight weeks. So here's the visit note. That was just kind of the synopsis of what happened. Here's the note. Chief complaint. Patient here for follow-up of a recent pancolitis flare. She was vacationing with her children in Florida when she started to experience severe abdominal cramping, diarrhea, and bleeding. She presented to a Florida hospital due to the severity of her symptoms. Since being treated at the hospital, her symptoms have improved and back to baseline. Past family social history, no changes since the last update in the chart. And there's so many times I see this when a patient comes in for a follow-up in the office, all of this information is regurgitated. It doesn't need to be in your follow-up if it's not pertinent or there's no change. Just making a comment there. Review of systems. Patient has occasional episodes of cramping, diarrhea, but is her typical baseline. No other symptoms were reported. Examination. Patient appears well, is pleasant, no acute distress, no abdominal pain, no tenderness. Valve sounds active. Okay. So did you see that? Let me go back to that slide. I don't have an essay on the history, okay? It's what has happened since the last time I saw the patient or what prompted them to come here, right? Same with history and review of systems. I don't have to have my template that checks every box for all these symptoms. If I'm not asking them, they should not be in my note, okay? It's got to be pertinent to the chief complaint. That's all we need. Exam. Again, appropriate to the chief complaint. I don't have to have neurology and psych and all this other stuff if it's not pertinent. Impression plan of care. Patient presented in here for follow-up of a recent hospitalization in Florida for ulcerative colitis flare, including severe abdominal pains, diarrhea, and blood in the stool. Her symptoms have greatly improved since hospitalization, but due to recent flares, I recommended her Remicade infusions be shortened down to six weeks from the current age. This was discussed with the patient in detail, and she agrees. We'll order the new infusion schedule patient to follow up with me in three months or sooner if symptoms worsen. All right. So I spent 15 minutes reviewing her records, 20 in history and exam, and 10 documenting and adding those new orders in. So if you add up that time, this is a level five follow-up. So if you think about it, by decision-making, it's nowhere near a level five because it's really, right now, it's stable chronic. That's a level 30, okay? So think about that. When you're seeing patients, and that medical decision-making doesn't get you to that level, but your time does, 99215 based upon 45 minutes of total time of care spent by the patient or spent in the care of the patient that day, okay? You can also document total time. You know, he broke it down on this example. There's nothing that says you have to break it down. I'm going to tell you it's best practice. But the bottom line is, if you are doing time-driven visits, you have to document the details to support your time. You cannot just put an impression plan and slap 45 minutes on the bottom of the note and bill a five. We have to know what made this a time-driven encounter. Here's another patient. This is actually a new patient. 53-year-old male presents for transplant evaluation. And this is just the impression and plan. They had a chief complaint history and exam documented. But this is a transplant evaluation. He's wanting to receive a renal transplant. Colonoscopy has been done in the past for this, but he states it's been too long since his last colonoscopy and transplant evaluation. So he's basically starting the ball all over. Plan. Colonoscopy, prep, education provided to the patient, and procedure will be scheduled. Benefits were discussed with the patient. I spent 45 minutes in total time. Approximately 30 minutes was spent with the patient. Communication was very difficult as he does not speak English. Communicated via translator over the phone. The remaining 15 minutes were spent in reviewing the patient's history and exam or documentation. So this is not a level four based on decision-making, all right? But it is by time. So you're probably not going to have a lot of these encounters where you're going to want to build by time on a new patient. But examples like this, definitely. All right, endoscopic risks, okay? So remember, we were talking about the endoscopy risks on the overall medical decision-making table. And so since we do a lot of this, I wanted to make sure you kind of understand that these are kind of where the levels fall based upon those assessment and plan plans. So the first one. New patient presents with complaints of nausea, vomiting, along with epigastric pain. We'll schedule the patient for an upper GI endoscopy at the ASC. Instructions were provided. All questions answered. This is a level three. So even though the complexity of problem is moderate, the risk is low. All right, let's take another patient. New patient presents with complaints of diarrhea and lower abdominal cramping. We'll schedule the patient for an outpatient lower endoscopy to be done at the hospital. He's at a higher risk for this procedure due to his underlying conditions of CAD, diabetes, severe morbid obesity with the current BMI of 46. That's a level four. Because we have a moderate for complexity of problems, but the risk is also moderate for minor procedure with identified risk factors. All right, well, let's take another outlook here. Assessment. This is an established patient who has recently been diagnosed with pancreatic cancer. Patient has significant pain, weight loss, jaundice, and fatigue symptoms. Recent imaging showed a significant stricture of the bile ducts. Plan. At this point, we recommend the patient undergo an emergent ERCP for stent placement into the stricture. This is considered a major procedure for this patient given the diagnosis of cancer, severe weight loss, and fatigue. Patient also has significant jaundice. Risk and benefits were discussed. All questions answered. All right, this is a five. The complexity of problems is high because you're dealing with a threat to life or bodily function if we don't get in and figure out what's going on. And high risk. Emergent major procedure for the patient. Okay? So you've got it. This is all about documenting. Put it in words. Put it in lay terms. That way, if a payer is looking at your level, you know, let's say you bill a level five and they're like, hmm, huh, we're going to request a note. We want to make sure it's a level five. There is no question here. There's no question this is a level five. It is very, it's in good detail, and it's for anyone, you know, because we have to keep in mind a little bit that those, you know, those that are looking at our records may not necessarily have an extensive GI medical background. So they don't know what we do. So we have to let, we have to put it, put it in there for them to easily gather and Oh, yeah, that's a sick patient. Okay. So again, all about documenting.

medical encounters

level of service

billing

documentation guidelines

pertinent information

time as determining factor