Good afternoon, everyone. Welcome back. I hope you're having enough time to both swallow your lunch without choking on it and enjoying yourselves. We'll launch into the afternoon sessions and I want to take this opportunity to thank our staff who make this entire thing possible for us. You've been hearing from Eden as moderator throughout the day, but also I want to give my thanks to Lyle Breams, who is our AV wizard. If you're ever at the auditorium at our ASGE facility and you look in the back, you see Lyle back there. Much of the time in this amazing instrument array, it really looks like a TV studio as far as I'm concerned, and does a great job. Michelle Akers, behind the scenes, does much of the organizing to help get this thing together and launched. I want to give all three of them our great thanks. What we're going to start with is a preview of some of the E&M changes and Medicare 2023, but talk about some ideas for revenue repair. As we started out saying, it appears that we're likely to be facing some cuts for 2023. The problem is even if we have a sparing of us from these cuts or we get a very small inflation adjustment like we did last year, we're still about 20 years behind the times in inflation for medical costs. The physician fee schedule is really unlike any other aspect of provider fee schedules, which has not had a significant inflation update for many years. We have to fight this battle virtually every year with Congress because the payment system is clearly broken. We're advocating not just for 2023, but we're trying to make a change in how the payment system works altogether so that eventually we actually do accomplish small but positive inflation updates just like we get for our ASCs, outpatient hospital, hospital for their DRGs, nursing facilities, pharmaceutical companies. Everybody gets an inflation adjustment except physicians. Here's a reimbursement question. In 2023, consult codes were reimbursed better than equivalent level of hospital admits or visits or outpatient visits. Do you think this is true or false? Here we go. Majority of you think that the consult services will not be reimbursed better than the equivalent visits. Thus far, that appears to be true by the RVUs and the times. I'll review a little bit of that. We used to think of consults, which obviously as specialists we do every day, as something that should reimburse better. We used to get reimbursed better, but CMS stopped recognizing consult codes long ago and they don't seem to have any intention of bringing it back despite entreaties from AMA and others periodically. But the valuation I think also has changed. It was a long discussion about whether to even keep consult codes when the E&M coding system was overhauled. There was enough clamor from the specialists to maintain them thinking that they were separate and distinct. But when it came down to the valuation, I think you'll see that for the most part, that's not where things went to. We're in what you could consider a reimbursement desert in a way. This is a beautiful place here in Death Valley, especially at dawn when the light plays across the sand dunes. But in terms of reimbursement, this is kind of where we're hitting 282 feet below sea level. This is bad water in Death Valley. When fees don't adjust for inflation, it's going to be very dry out there. So I do want to talk about a little bit more on the transition to the new E&M code descriptors and some of the billing rules, what does make up total time the day of the encounter for essentially all E&M codes as of January 1. A couple of points I'll make about medical decision-making complexity, which was I think handled very nicely this morning by Kristen. And then stressing though that the rest of the documentation should be based on medical necessity and sometimes medical legal needs rather than on fulfilling some arbitrary requirements like we used to have before. But there are what you should think of as minimal documentation standards. And when time is used to document, clearly your focus needs to be on both the medical necessity of the visit and what comprised the total time the day of encounter. Not necessarily that you need to put any specifics about how much time you spent doing this and how much time you spent doing that. But it needs to be clear to a sensible auditor that the time that you might use as the basis for your code is reflected in your documentation by the numbers of things that you're handling, the kinds of decisions you're making. In other words, the medical necessity of the visit needs to make sense for the total time. And when the total time you bill seems to be outside of what you would ordinarily require, there should be a reason. You may have a patient with a great deal of anxiety and numerous questions. You may be going through an interpreter and it just takes a long time to get the history out there or to explain things, etc. We've had some examples earlier today. On the other hand, when you're basing it on medical necessity, there still needs to be at least a limited amount of the history or exam and or medical decision making. They're documented and the focus should really be in the impression area to underscore your medical decision making on what are you thinking. That's what really underlies the risk. You need all parts that support medical decision making. How many problems have you been dealing with that day? You need comments on any of the diagnoses that you've actually been handling and making decisions about, even if no change. You talk to the patient about their GERD and you're making changes in management, but their constipation is doing fine on psyllium. If you ask them a question about the condition, you need to at least document constipation as a problem and that no change needed, the patient doing well, something of that regard. So it needs to be very clear what are you thinking and then the sense is then, is your plan sensible based on that? There's been no change in what comprises time except now in the hospital or other environments, the time is not just unit and floor time, but again, the total time the day of the encounter, whether you're preparing to see the patient, reviewing what's in the medical record, talking to the nurses and other caregivers, talking with family, communicating with other healthcare professionals, et cetera. So the care coordination, if it's not separately reported in some other way, is part of the time for that day. But keep in mind that when these codes were valued for their time by the RUC, the work RVUs were set with the thought that there is time during the three, it should be three days rather than two days, but three days before the actual encounter and 10 days after the encounter, some of the work done on behalf of the patient is figured into the reimbursement. So the concept is that you might think about billing things before or after that maybe have some CPT codes that look like they might fit, but if they really relate to a visit that's about to happen or a visit that just happened, you are likely to be sort of double dipping if you try to build separate codes. There are tons of parenthetical exclusions in CPT around E&M services that you don't build certain things that are very close in conjunction with or planning for an in-person encounter or telehealth encounter. So if you're not familiar with these, some of your newer providers are really not familiar with a lot of these exclusions and where the borderlines are between codes, you need to be sure they get well-educated. So 2023 hospital inpatient or observation care is overhauled to be very similar to the office codes and note that I said or observation care because we no longer have observation care codes that are distinct other than the admitted discharged observation the same day. Those have been retained but changed and all of the codes have a similar structure to the office and outpatient. So here's an example of a mid-level initial hospital inpatient or observation care per day for the evaluation and management of a patient which requires a medically appropriate history and or exam and moderate level of medical decision making. So it's the same sort of verbiage we've been living with now a couple of years for the office and outpatient and now these are adjusted for the hospital or observation environment. Keep in mind though that if you're doing a service which is in an observation care unit of the hospital, your place of service still needs to be observation care compared to if you're doing a hospital inpatient service. So we still need to keep track of the place of service even if the codes will be the same. And then the second part of each descriptor has to do with when using total time on the day of the encounter for the code selection rather than medical decision making. 55 minutes must be met or exceeded. So you remember we looked at a range of times for the office and outpatient. For all the rest of the codes, CPT and CMS are using a threshold minimum time that must be met or exceeded. So for example we're used to these ranges that were reviewed earlier today about the office and outpatient setting. There's a range of times. So in a sense the 99202 would require a minimum of 15 minutes met or exceeded but it goes up to 29. Well in the hospital we're just looking at threshold times. And note the 99417 prolonged service code which can be applied to office and outpatients. If you exceed the maximum, the 99215 or 99205 by 15 minutes or more, you can then report a 99417. Well there now is a 99418 code which is similar for the inpatient environment. Now what I put on this slide was the codes for 2023 for hospital and observation care on the left side and the inpatient consultation codes on the right side. And if you look at these, you can see that the minimum time thresholds are 40, 55, and 75 minutes if you bill based on time for the initial hospital visit, 25, 35, and 50 minutes for the follow-up established patient inpatient visit. The national fees that will be paid for these, which will be adjusted for your geographic locality, are going to be what are shown there ranging from about $100 to $200 for the range of inpatient admits and $39 to $102 for the follow-up. There is a 99418 code now that you'll be able to report if you exceed the highest level of those two sets of codes by 15 minutes or more. So that will be reportable, but it's pretty improbable that most of us would ever be spending that much time, 90 minutes for a hospital admit or more, 75, 65 minutes or more for a follow-up visit for a patient. So it'll be pretty rare that any of us use that 99418 code. But note that on the inpatient consult side, the 251 code we used to have is gone, just like the other level one codes. The 252, 345 codes are there with the various levels of complexity of medical decision-making. But note that the times involved are generally less than the counterparts for the admission. The exception would be a high-level inpatient consult, which requires 80 minutes to meet compared to 75 minutes for a hospital admission. And I'd argue it would be pretty rare we do a hospital consult that would require 80 minutes of time. Most of the time, if we're going to use consult services at all, it would be based on medical decision-making. So here are, for the outpatient services, the equivalent consult times. Again, the 242 through 5 reflect the same types of medical decision-making, four levels. But if you look at the time range, it falls right in the middle of the new patient 99202. The 243 code falls at the low end of 203. The 4-4 consult code falls below the level four visit code. And the level five falls below the level five hospital outpatient code. So you can expect lower reimbursement based on that. I didn't put the final RVUs here, but they are lower. So they're not going to, it's not going to be very cost effective, even for those contractors, those payers who recognize consult codes, by and large, it really won't pay you to do it. You need to look at your own payers, what the final fee schedules are. And, you know, sometimes you may find there's some advantages to it, but most times you'll find probably there won't be. Let's talk about a few of the related rules that CPT has published if you go through their guidelines. And if you buy a CPT book, it comes now with a small booklet that summarize a lot of what's new and different and distinct about E&M services and has the time data and so forth. It's packaged with the CPT book. It's a handy thing to use to teach your providers or to learn from. So what are some of the related rules that caught my eye that CPT considered and passed? Well, a transfer of care is basically considered a new or an established outpatient service or an inpatient admission service. It's not considered a consultation. It's basically you're taking over care for someone else transferred care to you. And so it's going to be a new or established patient, whether you've seen them in the last three years or not. And it's going to be an inpatient admit rather than consultation. If you use the consultation codes, there's only one consultation code used per admission with the same physician group or specialty, even if you're called back or one of your physicians in the group is called back about a new or the same problem. It's not a consultation. It's a follow up established patient hospital visit. And incidentally, if you let's say you do a consultation in the office and you know the patient's going to be admitted for basically the same problem, you then go in and see the patient. You're not going to build another consultation code. You're going to use a follow up hospital established patient code. So let's say you're an oncologist and you're planning chemotherapy and the patient gets admitted and then you're following through on your plan. Or you have a patient who you see in the office do a consultation for GI bleeding. You know you're going to do a colonoscopy or whatever the patient gets admitted because they're too unstable or they're too anemic. The follow up is not going to be another consult note or a first hospital admission note. It's going to be a follow up note. Now, if the patient is admitted and seen after admission, after a service in another site, using the office and outpatient codes, you can report the other site service of the 25 modifier. So that's different than the consultation codes, all different rules. OK, so those are some rules I picked out that I think are important to understand. And there are other E&M codes that GI folks rather seldom use. There are a whole set of emergency department codes that still exist. They have no times attached. There is a level one, which is a non-physician service, which we would never do. And generally, we won't use the ER codes ourselves. If we go into the ER to see a patient who is being admitted, it would wind up in effect an inpatient code. If they're going to be discharged back home, we'd usually be using the outpatient codes. But depending on the circumstances, you may want to use one of the ER codes. Those are distinguished only by medical decision-making complexity. So those may be circumstances when you see an ER patient who's going to be sent home and you'll follow up in the office, or you may wind up using a 282 through 285 or one of the outpatient hospital codes, consult codes. The SNF codes have similar changes as the office outpatient with medical decision-making and time. Again, GI docs rather seldom see SNF patients. And all of the domiciliary, rest home, custodial care, et cetera, were all merged into a home or residence set of codes, which could even be a hotel or a cruise ship. If you wind up seeing a patient in a cruise ship, there are codes now for levels new and established based on time or medical decision-making. So here is the ASGE cruise ship. If we happen to be taking care of each other or other patients, what's changed for prolonged services? Well, there used to be codes 9935455 for outpatient 5657 for same day direct patient contact prolonged service. Those are gone. The 99417 code is the correct code now. And Medicare now accepts that. Prolonged service with or without direct patient contact is the wording, but the minimum for that is each 15 minutes. So it's a minimum threshold of 15 minutes. And it can only be applied to the highest level of code in that family. So there's a very high time threshold, which I indicated there. The inpatient side, the new add-on code is 99418. Again, can only be applied to the highest level of the inpatient admit or the established patient follow-up or the observation same day admit discharge code. What about medical decision-making in regards to now extending this whole schema to the hospital inpatient side? Not much is different. It's really the same table, but there are a couple of added high-level medical decision-making risk elements added. So one of those is parenteral controlled substances use that qualifies as high risk. So it's sort of one step above the prescription management. A lot of times it won't be the GI doctor who orders the parenteral substances, but sometimes it will be. And the other is about a decision about escalation of hospital level care. So if you have a patient who has become unstable and you're the one helping to make the decision about moving the patient to a higher level of care in the ICU or observation unit, intermediate care unit, that would qualify as high risk. Somebody else makes that decision, then that's not for you to use. A couple of little things I'd point out about the medical decision-making. Again, the point was already made looking at the right side of this slide that the diagnosis or treatment significantly limited by social determinants of health applies to level four services. So what might've been level three may become level four based on that. But keep that in mind too, when you're trying to justify level five, when you have some borderline issues, if there's clearly a social determinant of health problem, that may also help you decide that a level five is justified. And main point I want to make on this is the level four here says one or more chronic illnesses with exacerbation, progression, or side effects of treatment. But the concept here is you have a non-stabilized patient and many of our patients are not really stable. And so when you think of a patient with IBD not doing well, a GERD patient not being well controlled on their current meds, IBD patient not meeting the point where you think that they should be meeting in terms of their treatment goals, this really fits within the concept of level four, one or more chronic illnesses with exacerbation, progression, or side effects of treatment. And there is language in CPT that addresses that, which I'll get to, but people don't get that concept many times if they only look at the table. And again, here in level five, the notion of what's a major surgery, as was already touched on, it's not a matter of a minor procedure being zero day, a major procedure being a 90-day procedure. It's what physicians think of as what's a high-risk procedure. So you can have a high-risk endoscopy in a patient that has significant comorbid conditions, and that certainly is major. So if you have a frail patient you're needing to do an ERCP on, or even a gastrostomy placement when they're very frail, their respiratory status is marginal, their cardiac state is marginal, this can well be justified as a major operation, major surgical procedure, and warrant level five if you're talking about the risk aspects. So again, in the CPT guidelines, the verbiage is stable for purposes of categorizing medical decision-making as defined by the specific treatment goals for an individual patient. A patient who is not at treatment goal is not stable, even if the condition has not changed, and there is no short-term threat to life or function. So this applies to many GI and liver disorders, and can be the difference between level three and level four. So keep that in mind. Another point, when it comes to the amount of material you're analyzing or reviewing or ordering, the distinction is tests ordered are presumed to be analyzed when results are reported. Therefore, when they're ordered during an encounter, they're counted in that encounter. If you order a CBC, the analysis of it is considered part of that encounter. On the other hand, if you order tests outside of an encounter, that may be counted in the encounter in which they are analyzed. So if you wind up getting a call from a patient, you order some lab work, you then wind up with a telehealth or some other visit later, the test that you ordered between visits can be counted for the next encounter. Or it may be part of things we'll talk about later in the day, a bundle of services that are really outside of the entirety of the encounter. A couple of other pointers that I call sort of my answers, because they're maybe not clearly addressed in CPT, but at least the way I interpret, I've already talked about the surgery minor or major. But the other thing that I think sometimes when you're using tests, and the number of tests you're analyzing and interpreting, one notion of independent interpretation of tests that I think does apply and can help move the level up in some cases. Keep in mind that there are many endoscopy reports we receive with color photos from a prior encounter with another physician. There are also many pathology reports we receive. And many times patients have a different idea or were told something different than what we may decide based on our own review of an endoscopy or pathology done before. Very common, for instance, that patients are told they have Barrett's when really this was intestinal metaplasia on a PATH report that probably was from the cardia of the stomach, not really true Barrett's. Patients are told they have serious gastritis based on, you know, some erythema by scope and nothing much pathologically abnormal. And if we really kind of change their diagnosis or their treatment plan based on reviews of these documents, I consider that an independent interpretation of tests. Now, if you don't have good photographs, you can't do that from a scope report if you don't have the PATH report, you know, so you can have a different impression from the patient without that documented material. And I already commented on the social determinants of health. We've covered a lot of these ICD-10 codes, but our providers really need to get very familiar with these, particularly some of these areas of noncompliance, medication underdosing because of financial hardship, or because the caregiver just doesn't do it right. There are chronic fatigue syndromes and post-rival fatigue now we have codes for in the COVID era. Insecurity, unable to obtain basic needs, financial hardship for non-adherence to medical treatment. So these will be useful codes that we need to be sure are updated in our EMR and could be found fairly readily. And one other general point I wanted to make about E&M visits compared to procedural activity. Most GI practices earn about two-thirds of their revenue from procedural income. But the more we look at what's happened with E&M code reimbursement, and what's happened with endoscopic reimbursement, on the right you can see a few common endoscopic procedures. 43239 is reimbursed for physicians in LA. This is LA data. About $149 or a diagnostic colonoscopy or screening colonoscopy about $200. Well, you can look at patients in the office and for a level four or level five new patient, it's probably more productive to spend your time doing E&M visits. And even for follow-up visits, again, levels can go up to almost $200 for a level five and $150 for a level four visit. So we should sometimes rethink about how we're spending our time during the day instead of just pushing procedural volume, maybe doing more of our E&M services can be productive for us. If we do nothing different, I took this photograph when I was down in Patagonia walking along the harbor there before heading off for Antarctica. And this sobered me up considerably because going across the Drake to get to Antarctica in a boat is inherently a hazardous business, but running a GI practice these days also. So how can we do some E&M repair? Doing the same old won't cut it. A lot of us still under bill, we do a lot of complex decision-making services. We used to bill level fives about 20 to 25% of the time back in the 1990s. Now we bill 5%. Are we really seeing simpler patients than we used to? I don't think so. If we can fit in a few more higher level, level four, level five patients each week, that alone can add some extra revenue that can wind up being substantial if they're higher level codes. A couple more slots per week, if you can add some extra time. We forget about such things as smoking cessation counseling, which we do many times in conjunction with our visits that can be billed separately. It's just five minutes or more or 10 minutes or more. Pays a little extra, but we do these things commonly with our patients who are smokers. We forget to bill for them. Some GI practices have set up to do chronic care management and this is utilizing staff, not physician time. For patients with two or more chronic conditions, we can be billing the 99490 code. If we're actually doing this through our staff, it's a 20 minute per calendar month service. At $46, it can add up over time for patients that you're chronically managing their two or more problems. If we're getting in our huge medical records in between visits and we don't review them the day of the visit, but either before or later afterwards, there is a 99358 code, prolonged services, different day. I do utilize these codes when I spend more than 30 minutes going through a large record. We now get these 100, 200, 300 page files generated by Epic and Kaiser Permanente. They just send us everything that is in their system. We have to go sort that out and find the five or 10 pages of important information we need to summarize. This can be incredibly time consuming. These codes are very justifiable. We'll spend some time a little later talking about telephone services, other online services, et cetera. Again, we're forgetting to bill a lot of these, even though we perform them. We already talked about pre-colonoscopy visits. I won't go over that again. Here are the codes for the staff-based chronic care management codes for two or more conditions. There are a lot of rules that pertain, but a lot of particularly larger practices have set up ways of having programs for these. They're quite useful. You can sometimes combine them with monitoring through some of the physiologic events. We have patients with cirrhosis and dysidiasis who really could have an electronic scale and be transmitting data. That's another set of codes. Many of us forgot the fact that we now have principal care management codes where it only requires one high-risk condition. Again, you have a serious patient who is, let's say, gastrostomy tube fed or has cirrhosis with ascites and does need a lot of follow-up. If clinical staff can do that, there are codes. This requires the first 30 minutes of staff time directed by a healthcare professional, by a physician. Again, these actually pay pretty substantial amounts. The $64 now for 2022 for the 99490 code and the equivalent for principal care, $62. If you set up methods to do this with either your own staff or staff of an outside company that you can make arrangements for, it can be very profitable. Good patient care. Medicare is encouraging coordination of care. We can still do care plan oversight. We do have patients who are under home health management. They may be getting parenteral nutrition or some other very complex care where we're involved in their follow-up. 15 to 29 minutes of such service can pay over $100. Examples are patients on home TPN who require regular lab review and revision of orders and assessing the status of the home health. Occasionally, enterally fed patients also need a lot of changes in management done through home health but under our supervision. Home health certification and recertification, those codes still exist and they pay quite reasonably well. Some of us are the ones who recertify or certify home health for some of these patients. We may be putting in a gastrostomy tube and then they're followed by home health. We may be involved in overseeing their care. We're not necessarily doing the care plan oversight, but we get the orders to review and to sign. We're not necessarily remembering to bill for for some of these things. There's a lot of these little services. Remote physiologic monitoring, I've mentioned, and there's probably going to be gradually more of this type of activity done for patients with some of the complex GI issues. Here, there's a potential of a number of different codes for enrolling the patient and getting it set up and managing the care based on time. This will be more future than current coding, but the point is there are more opportunities as we're doing better care management. Again, here's another environment, Sabrisky Point. This photograph was taken at dawn and enhanced to bring out the landscape and its rugged beauty. There is something out there that's hopeful. I've just closed saying that opportunities and threats both sneak up on you. This guy followed me through Yellowstone a couple of winters ago, walking behind our Jeep. Coyote was totally unabashed, but we enjoyed watching him walking with us. OK, I'm going to hand this off to Kristen then to talk about some of the other thorny issues that CMS confront confronts us with.

Evaluation and Management codes

Medicare changes

Physician fee schedule

E&M code descriptors

Medical decision-making complexity

Reimbursement rates

Billing for specific services