Welcome, everyone. All right. So, as Dr. Littenberg said, we're going to talk about the new events. And before we start, though, polling question number one. So, good morning. Are you ready to go? And like Dr. Littenberg said, depending upon where you live, you're going to have a different answer, I'm sure. So, what are you drinking this morning? Coffee, water, juice, tea, margaritas? That's 5 o'clock somewhere. Or you can also do, what did you have for breakfast this morning? Coffee, juice, granola bar, full breakfast. All right. Or are you kidding? I am still in bed. All right. So, all right. All right. And then the next question we're going to talk about is how many of you guys are listening this morning? How many members of your team? So, one of you, two to three, four to six, or seven or more? Wow. Okay. A nice variety. Okay. So, as we go through today, make sure, and if you have any questions, put them in the Q&A, and we'll get to them. And past years we've had quite a few questions, and that's great. We love to have audience participation. So, we're going to talk about the changes to the 2024 fee schedule for both the ASC side as well as the physician side. We're going to talk about the CMS screening colonoscopy update, the new CPT codes, the ICD-10 codes. And we may not spend as much time in this first presentation. And as you know, and it was published in the brochure, that some of the time slots are subject to change. So, I guarantee you guys, we sometimes will not do as much in one session as we do in the next session. So, again, we want to make sure that we leave plenty of time for any of your questions as well. So, let's talk about the ASC update, and that's actually the better news. Okay. There's a 3.8%, and it should be on October 31st of 2023. The four codes were added, are still suspended through 2023. The ASC measures 9 and 12 for GI endoscopy. All right. And please download the information before that's published in red. There is a new ASC measure that has to do with COVID-19 vaccination among healthcare workers. All right. And the measure specification lists are, you know, obviously if somebody has a contraindication to COVID that are described by the CDC. So, not too many updates as far as the ASC measures go. As far as the physician fee schedule goes. All right. So, this was actually published on November 1st, and what happened is we still got the decrease, like Dr. Littenberg said. It's going to be $32.74 per RVU, which is a decrease of $1.15. I've got the link here if you have not looked at the final rule. This is just the fact sheet. Just basically an overview. So, guys, as in previous years, you know, this, even though it says it's a final rule, this may not be final just yet. There's petitions from the AMA and various organizations to CMS and to Congress to see if they can, of course, not push this through and not decrease it as much. May not go into effect. May not go through this year. We've got some issues with the budget that Congress has to work through as well. So, we'll see what happens. See if this actually does go through. We probably will not know until mid-December. Now, split or shared E&M services, and Kristen is going to go into a lot more detail on this, but this has to deal with two providers. So, we're talking about physicians and non-physician practitioners in hospitals and institutional settings. Split share does not apply to the office site. So, they're finalizing the revision to the substantive portion of the split or shared visit. All right. Substantive portion means that more than half of the total time spent by the physician or non-physician practitioner performing the split or shared visit are a substantive part of the medical decision-making. And honestly, guys, this is really what we're looking at now. You know, the history and physical don't impact decision-making anymore. They don't impact the level of visit. So, our visit is either based upon time or medical decision-making. So, as you all know, in 2023, it was supposed to go through, and then they postponed it to 2024, that it was not going to be an either-or situation. It was either going to be, it was going to be more than 50% of time, and that's the provider that would bill for that, but did not go through at this point. So, this responded to public comments asking that we allow either time our medical decision-making to serve as a substantive portion of a split or shared visit. And I can tell you just by our client base that we deal with at Ask Miller is, you know, we deal with university settings, we deal with private settings, et cetera, you know, and, of course, hospital. And there have been quite a few practices that have pulled their advanced practitioners out of the hospital side because, obviously, most of the visits would go towards the advanced practitioners and not the physicians if it's based upon time. You know, that doesn't make a lot of sense to us on this because, obviously, your advanced practitioners do spend a lot of time in the hospital. And when you're looking at a 15% differential difference on this, it may not make sense for your physicians to see the hospital patients as far as time-wise and whether or not they can do more endoscopy procedures over visits. So, again, that's something that your practice has to make a decision on, but I think right now it's kind of like, okay, we're still in the status quo here where it's an either-or situation. All right. So, multiple evaluation and management services on the same day. So, this was also an update on this, and we'll talk about inpatient observation, ED, and skilled nursing. So, the hospital inpatient and observation care services and SNF visits are considered per-day services. And so, when multiple visits occur over the course of a single calendar event in the same setting, we can only bill one service. And this is really not new, all right, but they just are, again, trying to put this out so everybody understands it. So, when you're using medical decision-making for code-level selection, you're going to use the aggregated medical decision-making over the course of the calendar day. And we all know patients can change in the hospital setting. So, in the morning, they may be doing well, and they deteriorate over the day. So, but when using time for code-level selection, you're going to sum the time over the course of the day using the guidelines for reporting time. All right, so, again, the decision-making, again, versus time. ED and services in other settings. So, time spent in the emergency room by a physician or other qualified healthcare provider who provides subsequent E&M services, maybe including and calculating total time on the date of the encounter when ED services are not reported. So, the thing is with ED, you cannot bill by time in the emergency room, all right? So, you know, so it's going to be usually if the patient's in the emergency room and gets admitted, all right, we do not bill the ED. We bill where the patient ends up versus hospital inpatient or observation care services. All right, so times for new and established patients. So, I think, you know, for those of you that are familiar with a time-based billing, it was a variable in here. So, it says instead of time ranges, there are now set times. It used to be 15 to 29 minutes, 30 to 44 minutes, et cetera. Now it just says 15 minutes must be met or exceeded. 99203 is 30 minutes must be met or exceeded. 99204 is 45 minutes must be met or exceeded. And 99205 is 60 minutes. So, if you're not familiar with the numbers, these are new patient visit times. So, level 2, level 3, level 4, level 5. And so then we go to the established patient visits that are 99212, 3, 4, and 5. And we're looking at 10, 20, 30, and 40 minutes. And I'm still seeing when we're doing reviews, all right, we still see that a lot of the providers still have the mindset that a level 4 meets 25 minutes. It does not. Remember that when you're billing by time, it's not just the time with the patient. All right, it's total time. So, it's the time spent in reviewing internal records. All right, the time spent examining the patient, taking the history. So, we're talking about face-to-face time. It's also the time in counseling and coordination of care. It can also be time spent with the family, as well as time with other providers, and also time on documentation. So, it's the whole gamut on that same calendar date. And that's very important. It has to be on the same day. So, the hospital is the same way. Everything now is the same since January 1st of this year. Time thresholds for the hospital are different. All right, so this is just new and established patients. We just have now at least this has to be met or exceeded. And take this also into consideration, you cannot up-code. So, just because you got to 29 minutes does not mean that, oh, okay, we can round up to 992 or 3. No, it has to be at least 30 minutes. And just Anthem, Blue Cross and Blue Shield, all right, has basically been a little bit more picky with this now, all right, as far as your time. Remember what I said, it's the time in reviewing, the time with the patient, and the time in documentation. All right, they actually want to see the breakdown. So, Kristen and I have kind of said this for a long time, that the best practice would be to break this down based upon how much time in each of these categories. All right, so but Anthem is basically saying if you don't have this documented, we're not going to give you time. All right, and we're going to base it on your decision-making threshold. And this is kind of the take-home on this. Best practice on using time. When the decision-making doesn't justify the level of visit, but time does. And I don't think you should be using time on everything. You know, and this can actually, even though the guidelines say that they'll give you the level based upon time or decision-making, you know, remember that you're dealing with some auditors that don't have that. Let's put it this way, they don't have that mindset. So, once they see time documented, they kind of ignore decision-making. And that, of course, is not the guideline. But if you get reviewed and they, you know, they downcoded you because you had 30 minutes documented, but your decision-making actually justified a level four status, I mean, you can always dispute that. But again, it takes time to go back and try and dispute and overturn a pair that has downcoded your levels. All right, so best practice would be not to use time unless your decision-making did not justify the level. And I know it's hard sometimes to get into habits on this one. You get, you know, it's like, well, we're going to put both down, you know, so whatever is better. Now, try to get in the habit of decision-making or time, not decision-making and time on documentation. All right, so hospital and inpatient are observation care services, including admission and discharge services. So, in order to build codes 99234, 235, and 236, which is actually the admission and discharge one code, the patient stay has to be greater than eight hours. And there has to be at least two separate visits in which one visit is the initial visit and another being a discharge. And honestly, I don't see GI doing this a lot, simply because most of the time the admissions now are done by the hospitalist. All right, so that's going to be more applying to them. But I'm not saying that you're never going to do this. I'm just saying that most of the time we have one visit and it's usually going to be the admission. So, if the patient stay is less than eight hours, then only initial inpatient or observation codes can be built. All right, so this is just a little tidbit on observation care. The admission to observation, all right, even though CPT says something different, all right, then it can be done by more than one provider, right? Most of the payers, including Medicare, all right, state that the only one that can build observation care services is the provider that admitted the patient. If you did not admit the patient, then you would build observation care by a new or established codes, kind of the same guidelines as the office site. All right, so that does conflict with the CPT guidelines, and it has always done that way. You know, even though we have the changes this year on January 1st, we have seen that Medicare and most of the commercial payers only allow for observation admits to the admitting provider. All right, so again, that's just something in the back of your mind. And I'm sure some of you that are coders and billers that are listening in can kind of understand what I'm saying on this one? Because the fact of the matter is that the payers really have been denying claims saying that it was previously billed by another provider if two of you billed the initial inpatients as our initial observation care services. OK, the 2024 new CPT codes. There's one. That's it. So we've got 0813T. This is a temporary code. This is category 3. Esophageal gastrointestinaloscopy with a volume adjustment of a bariatric balloon. So last year, we got the new codes for the bariatric balloons. And now we have a volume adjustment on this one. But this is a T code. Usually, the facilities get paid on the T side. Most of the time on the physician's side, if we submit a T, you usually get a denial. And we are usually going to be using an unlisted procedure code. But this is the code that you would submit. Now, as far as the ICD-10 codes, and Kristen is going to go into more detail on ICD-10 and risk adjustment shortly. So the new codes that are effective on October 1, we have D13.91, which is FAP. If you realize, we also have another code, D12.6, that basically said FAP. So D13 is upper GI code. And the D12 code is a lower GI code. So sometimes when ICD-10 makes their changes, it can be questionable. Because we have not seen any payers now that have adopted D13.91 as an approved diagnosis code for colonoscopy. So we have to look. A lot of times when we have changes to the ICD-10 codes that the effective dates are October, we don't see necessarily the changes to the local coverage determinations or policies by payers, sometimes for a few months. So D13.99 is benign neoplasm of ill-defined sites within the digestive system. We have some bacterial overgrowth codes. So hydrogen subtype, hydrogen sulfide subtype, unspecified, fungal overgrowth, and methanogen overgrowth, unspecified. So interesting codes. And I'm sure some of you will be using them. Then we have Sharp Bowel Syndrome with colon incontinuity and Sharp Bowel Syndrome without colon incontinuity. So I'm sure some of you, especially, that are maybe listening for it on the pediatric side might be using this a little bit more. And Sharp Bowel, though, we do have some adult patients that have this. Then we also have an intestinal failure code. We have another congenital malformation of liver code, allergal syndrome, and then other congenital malformations of liver. And this next code is kind of a nice, I think it's a nice code. It's R09.82. This is foreign body sensation of the throat. And I think you guys will be using this code. So if you don't know what's around, you may use this. So may globus sensation, a lot of times that we see this assigned. Globus sensation, if you look at this, globus sensation, if you look at this, it actually is a psych code. And so when you guys diagnose globus and it goes out as a psych diagnosis, it may not automatically get approved, obviously, for EGD. And this has not been approved yet by most of the payers either. But it still would be a good diagnosis code for a visit. So anything that begins with an R means it's a sign or symptom. So when you're looking at, it's actually an F code that's considered a psych diagnosis. You only want to sign out when you've ruled out any type of physiologic cause. So anything that begins with an R, and I know providers, I don't expect you to have all these diagnosis codes memorized. But anytime you see an R and it's the first in ICD-10, that actually is a really good code to use, especially if you're going to do additional diagnostic studies, EGD and colonoscopy, it's because this patient is a symptom. We don't know the origin of the symptom just yet. So it's really a good code. All right, the thing is you probably are going to be ruling out some things. There is no code for a rule out. So why are you ruling out something? It's usually based upon a symptom. All right, now we've got four other codes coming out. Family history, it used to be Z83.73 or 71, sorry. Now it's out to six characters. Family history of adenomatous and serrated polyps. Family history of hyperplastic colon polyps. Other family history of colon polyps. And family history of colon polyps unspecified. Wow, when I looked at this, when we saw the codes come out in the very first part, I'm like, who in the heck knows this? All right, we have trouble even getting, it's always been something that we have asked our providers that when they document the personal history side, that they specify whether the patient had personal history of adenomatous or self-serrated or hyperplastic in there. Because it does affect what codes and especially your recall on these patients. All right, so on family history, how would you know unless the patient actually told you, oh yeah, this is what my mom had. She had adenomatous polyps. Most of the time, they said, yeah, they had polyps. And if you ask about what type, I don't know. All right, so unless they're bringing in path reports for their family, you're not going to know this. All right, so most commonly, I think we're going to see just family history of colon polyps unspecified. And that right now is not approved. That's not considered an indication because the LCDs have not been updated just yet for this. All right, so and then we've got four new caregivers noncompliance with patient's medication regimen due to financial hardship for other reasons. And then caregivers noncompliance with patient's other medical treatment. So again, back to the caregiver. So we do have patients that are not able to make their own decisions. And so they are basically under, let's put it this way, under the caregiver's guidance in particular. So if the caregiver is not following through, it does affect your care plan. And like I said, Kristen's going to go over more of this, especially when she talks about the medical decision-making part of your visit. But I'm just telling you, these codes are out there. And they start with the Z55 area. And they're very important. And it's something that you also should be putting in your impression and plan, in your care plan, because this can affect your care plan. So what happens if the patient is noncompliant, either because they are noncompliant or the caregiver is noncompliant? It affects their what? Overall outcomes. All right, and so they may not be getting better. They may be getting worse. You may be admitting them because they're not following through with your care plan. You're not a bad provider. You know how to treat patients. It's just they're not following through with your recommendations. And so when you're looking at outcomes in particular, and you're looking at risk adjustment, if your patients don't do as well as other patients or other providers' patients, it kind of makes your record look bad. So these should be put in your impression and plan. And remember, what's in your impression and plan is what actually gets assigned to the claim. Your electronic health care systems, you've got a format in there. You've got the history. You've got the physical exam. And you've got the assessment and plan. And providers, I'm so glad that you join us today, because this is so important. What you put in the assessment and plan, like number one, number two, number three, those are what goes on the claim. Anything that's considered free text, the system does not pick up and does not assign that ICD-10 code on your claim. And remember that the first diagnosis or the first problem that you put in the assessment and plan is actually what affects medical necessity. That primary diagnosis would support your level, would support medical necessity for your procedures. And then the additional diagnosis could support the level, help to support it. We can put up to 12 diagnosis codes on a claim. But remember, only those that affect your visit in your care that day should go on the claim, not to use your problem list. But actually, those that you're actually managing and affect your decision making should be assigned. Again, remember that, just like with obesity, if you put down obesity or you put down morbid obesity, we should have a corresponding ICD-10 code for the BMI. And so that actually can be another diagnosis. So the more information we put on the claim, the better we are at supporting the level, provided that, again, you are actually managing those conditions. So they also moved an excludes one status to exclude status two on a one code in particular. And that's a D12 code, which is up in my neoplasm of the colon and the K63.5 for the colon polyp, which would be the, this could actually be an inflammatory polyp on a patient that does not have IBD, or it can be a hyperplastic polyp. So what does that mean, excludes one? It means that these two codes cannot be built together. Excludes two says that they can be built together because there are usually what, different polyps, different areas, different lesions. So for the example, if a SNIR polypectomy was performed on both the polyp and the cecum and the sigmoid colon, if the polyp and the cecum returned as an adenoma, that would be D12.0, and a polyp and the sigmoid returned as a hyperplastic, that would be K63.5. We can now build both of these together, right? Before October 1st, if we built them together, we got a denial on the claim. Okay. On colorectal cancer screening since January 1st of 2023, Medicare reduced the minimum age patient payment and coverage limitation from 50 to 45 years. And I'm going to be talking more about the screening guidelines in a little bit. All right. After break today. So Medicare reduced the minimum age. They finally started to follow the Affordable Care Act guidelines. And remember that Medicare or CMS does not follow the ACA. They kind of have their own guidelines. But on this one, they have started to follow this. So they also expanded the regulatory definition of colorectal cancer screening tests to include the complete colorectal cancer screening. So it says we're a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based colorectal cancer screening test returns a positive result. A functional outcome of our policy for a completed colorectal cancer screening will be that for most beneficiaries, cost sharing will not apply for either the initial stool-based test or the follow-on colonoscopy. So they started this on January 1st. The Affordable Care Act finalized and started this on May 31st of 2022. And I'm going to be covering this a little bit in more detail, but again, this started the guidelines for Medicare as well since January 1st. All right. And they also established a new modifier, but this was published and this is, we've got the link at the bottom. This was published actually on February 27th of this past year and the effective date was January 1st. So a positive result from a non-invasive stool-based colorectal screening test no longer requires that the follow-up colonoscopy be diagnostic. All right. So basically they're stating, and in red, attaching the KX modifier to a screening colonoscopy code to indicate such service was performed as a follow-up screening after a positive result from a stool-based test. All right, doctors, listen up on this. Please make sure on your indications, on your colonoscopy endoscopy procedure note that the indication is a positive screening stool test. So a positive screening fit, a positive screening Cologuard, a positive screening Guayac. All right. Because we all know that for the fit in the Guayac, it can be done for patients that are symptomatic, have iron deficiency, anemia, et cetera. All right. So you want to make sure that you state this is a positive screening test. All right. That's definitely a takeaway for today. Okay. So, we have definitely more issues that we're going to cover today. We're going to talk about ICD-10 and HCC risk adjustment. We're going to talk about an overview on all A&M codes. All right. So now we don't have any major changes anymore, but we still have a, let's put it this way, a great misunderstanding, especially on decision-making. All right. So we're talking about screening versus diagnostic. We're going to talk about medical necessity. We're going to talk about pathology and ancillary services, anesthesia services, the top issues impacting GI. Dr. Littenberg's going to talk about artificial intelligence. So we've got a lot, lot more to go through today and stay tuned. And I'm going to turn this over to Kristen for the next presentation.

medical billing

coding

gastroenterology

ambulatory surgical centers

CMS screening colonoscopy guidelines

CPT codes

ICD-10 codes