Patty Garcia, who is a ROCA and CPT representative from AGA, who works on our coding and reimbursement team. She's at Stanford and a motility specialist. And Ed Sun, who is a CPT advisor for ASGE. Now I'm the alternate advisor, having helped mentor Ed along. And he and I are coordinating our CPT activities for ASGE. So I want to address a number of the things that physicians really have been doing all along, and yet often not taking credit for. But I wanted to start with a couple of simple coding questions. I think we've kind of hit on this earlier. You know, in recent years, the percent of complex new patients in GI in your practice is what I'd like to get feedback about. We talked earlier about, in general, it seems to be a very low number. But wonder if you have your own notion and your own practice of how frequently you're billing at a high level for complex patients. So about 5%, about 15 to 20%, about 25 to 30%, greater than 30%. We're just interested in your answers if you know. Okay, well, that's interesting, and yet it seems to contradict what the actual benchmark data shows, which is around 6% level fives for new patients in GI. But I hope your answers are accurate and true, and I think you ought to go back to your practices and double-check if that's really the case. Because I think probably D greater than 30% is accurate, appropriate for many practices, but certainly somewhere B, C, 15 to 30% I think is realistic even for fairly busy practices with a mix of general GI patients. Because you do have your new IBD, your new cirrhotics, you have the complex functional patients who have had extensive workups elsewhere, et cetera, and people who just are very time-consuming, and yet maybe you bill on medical necessity instead of on time, things of that nature. But there are also a lot of other things that we do that I want to spend some time talking about that could bring extra revenue, but recognize the work that you're doing. So my comment here is life is short, coding is long. There are a lot of things we often just don't think about, and we should, and part of why we need to do that is because we're just getting more and more behind. I talked about the turkey that has landed this year from CMS on physicians, where again, we get a sort of a meatless wishbone. This illustrates the fact that physician updates have lagged behind anything, whether you measure the Medicare Economic Index, which is what it costs to run a practice, to how other aspects of medical care are reimbursed, outpatient hospital, ASC, nursing facilities, prescription costs would be going up at an even steeper angle if you were to look at it. But physicians are the only Medicare providers who do not receive an inflation or market basket increase annually. And part of that problem is we just cannot manage to get Congress to focus on it. And part of it is because when it's scored as far as the budget impact by the Congressional Budget Office, which tries to be neutral, but comes up with what a 10-year cost would be like, it's always a very large number. And of course, it just gets larger and larger the more behind we get. But there's more and more concerted activity to try to change the way physician updates are done and try to move us along. So we do have a serious problem. We're now about 26% below the rate of inflation versus many folks who have gotten significant increases for other categories of providers. And we're looking at a 3.4% further cut in 2024 unless Congress steps in. And we're trying to lean on them, but probably at the best, we're going to get that 3.4% cut, maybe cut in half. That's if a Senate bill moves along. So we're now looking at conversion factor in 2020, that was 3609, going down to 3274 next year, 10% further reduction. So not good. And many of the things we just are having problems with in our practices really reflect that. I'm going to actually skip this coding question because I think we've already answered that. It's false. The percent of level five visits in GI is way under what many other medical subspecialties, neurology, rheumatology, ID, et cetera, bill even currently, which it's often in the range of 25% or higher. We're still way under that. And this year, what was said in CMS's self-congratulatory notices, they're going to support primary care, assist family caregivers and advance access to behavioral health and certain oral care. So dentists taking care of cancer patients have a win this year. In CMS, physicians definitely do not. So citing Oscar Wilde, an optimist, telling you the glass is half full, the pessimist half empty, the engineer telling you the glass is twice the size it needs to be. I'm afraid our glass is half the size it needs to be. So what can we fill it with? There are other things we do. Stuff does slip through the cracks in our everyday work that we kind of forget we can bill some of for and some of it we have to make some adjustments. I refer to these as the other codes. My thanks to Leica Studios and Coraline here for pointing out the other mother and the other father. Well, the other codes are what we need to focus on here. Many GI groups have tried to fill in what is deficient on the professional side by many other services, a larger, more organized GI groups do from running their own pathology labs to having ambulatory endoscopy center ownership interest in anesthesia, at least partial replacement, having their own CRNAs. Other things, research, nutrition services, chronic care management, in-house pharmacies. And the only reason that GI continues overall to do as well as we do is because many of these activities have been developed to add to what our professional fees are but there are a lot of EM codes we just don't think enough about and I'll go through a few of these and there's some I don't have time for today but I will focus on transitional care services, some of the portal-based internet services we do for patients, some of the telephone services which are not telehealth, I'm talking about just making phone calls back to patients who inquire of us, they need help, other online services. But there are a whole host of chronic care management services that if we organize properly, some of our staff can be providing and we can even outsource some of this to some of the staff that are not directly employees of our practices and yet can be helping us keep track of patients with either one serious health condition or two or more serious health conditions. And this can be a monthly or periodic service which can be a significant source of revenue plus help improve patient care for patients who many times just aren't going to tell you when they're sick or deteriorating and yet they're very much at risk of being sicker and deteriorating. We also often forget to bill for the home health certifications and recertifications which do have separate CPT codes, they're G codes but they reimburse significantly and some of these are sent to GI doctors, not just primary care. Some of us oversee home TPN patients and enterally fed patients at home and so we provide care plan oversight and sometimes we just don't realize we're doing this and yet again, it's something we could be billing for on a regular basis for these unusual individuals. What else are potential cash services that maybe there's no billing for but nonetheless, there are things you can do. Some areas have administrative fee when we're processing the open access colonoscopy patients without seeing them at the office because there is a lot of work, staff time, some physician time that goes into doing this properly and it is feasible to build some administrative fees into this and at least some areas where you practice, you can be selling prep kits, you can be involved in nutrition supplements and having those part of your own practice, many patients are quite interested in these and it's not hard to introduce this as an additional service. Breath testing done for conditions of functional bowel diseases, many of these may not be covered by insurers and yet they are valuable, they help us manage patients, patients have a great interest in this. Nutrition services, touched on briefly, some of the nutrition services do have codes and can be billed by a variety of individuals even though many health plans may not cover it, there are many patients who are willing to pay for those services, integrated healthcare, behavioral health, all other areas that practices could be spending some time developing and some of again, larger groups are offering. But let's talk briefly about transitional care, this has been out there for a long time, there are two CPT codes, 99495 and 99496 and this has to do with patients who are being discharged out of the hospital and need to be seen either within seven days or 14 days from discharge from the inpatient setting and when it's more urgent, they need to be seen within seven days, this typically involves decision making of high complexity whereas if they can be seen within 14 days instead of seven, usually this is moderate complexity services but they reimburse well over twice what a typical office visit of a similar length would pay. Both require that there be communication with the patient or caregiver within a short time to business days of the discharge and this is kind of a hurdle for practices to be able to get this organized and then basically there's a 30 day package of services that begins the day of discharge and the fee can be reported after the actual face-to-face visit occurs or it can be billed at the end of the time of the service in the end of the 30 days, either way. But how do you actually get this organized and done? Okay, again, so there are two codes, moderate complexity, high complexity based on the length of time, the face-to-face visit needs to occur within this eight to 14 day timeframe for this to be something you can utilize. So typically with these components, the healthcare provider in the group seeing the patient in the hospital has to make sure the staff knows to schedule a visit in the seven to 14 day window and staff needs to do this interactive contact with the patient within a couple of days or at least be trying and documenting even if they don't get through, you have to have at least two tries within two days and try to get it done. And what that contact is, is setting up the visit, being sure patient for instance, got their medications prescribed so that they're on their GI meds, the GI doctor may have prescribed for them and set up a face-to-face or telehealth visit within that period of time. So commonly the medicine reconciliation is done and ultimately that is provided to the patient that they have a medicine list. So we're doing much of the components of this when we're seeing patients within two weeks of discharge but that interactive contact is often missing and if you can build in your work sequence to get this done then you can bill for those services and get paid quite substantially after that visit. Let's talk a little bit about telephone services, telephone E&M services. There are rules in CPT and it's important to review these if your providers wanna utilize these on a regular basis which is quite reasonable. Basically these are services that take the place of what would otherwise be a face-to-face visit or a telehealth complete visit, video visit. So when a patient is calling about a problem, let's say they're having a recurrence of their diverticulitis, you haven't seen them in the prior week, you don't think you need to see them in the next 24 hours or the soonest available appointment. You feel you can handle them through a phone visit, maybe a follow-up telephone chat. It's very legitimate to be billing 99441 through 99443 for anywhere from five to 10 minutes of medical discussion with the patient or up to 21 to 30 minutes of medical discussion. And it's a legitimate thing to bill and Medicare has been paying for these and many private payers have paid for these for years. And yet physicians often just kind of forget about it. They may note something in their chart, but many times I spend five, 10, 15, 20 minutes and yet they don't bill for it. So here's a typical telephony and M clinical case. You see a patient for constipation, face-to-face visit or telehealth visit, you advise them on their fiber and MiraLAX, you schedule them for a follow-up in six months. Months later, the patient calls to say, yeah, they're trying these things, that it's just not working out. You want to, they want to know what else you can do. You either make a telephone visit encounter or set one up and you spend time discussing the situation, finding out again, what's going on with the patient and their diet and how they did try these things. You may decide to prescribe lenacletide or some other prescription drug and you create a brief note, just documenting the date of the service, the content of the discussion doesn't have to be lengthy. Patient should be aware that there can, there will be a copay charge potentially for it. And if it's of this 15 minute duration, you can then be billing 99442 for that date of that service that you've documented. So again, Medicare rules say it can't originate from a related service in the prior week or lead to an immediate new patient visit. Right now, during the public health emergency, it was for newer established patients. We're back to being able to do that for established patients only. So it should be patient initiated, okay? But this is often the situation. And how much are these being paid right now for the five to 10 minute service? $56 for a really lengthy, which is not common, up to $128. These are the national average payment rates. Your rates may be a little higher or a bit lower depending on the geographic area, but certainly significant amount of dollars per minute of talking to the patient for very legitimate reasons. And your providers may be doing these things without really taking credit for them or establishing billing for them. There is a somewhat related set of services, 99421 through 23, which are referred to as online digital evaluation management. And again, these are for established patients and it's a cumulative during a seven day period of time. Again, has timeframe that goes from five to 10 minutes, 11 to 20 or 21 or more minutes. What these are basically a series of internet-based communications commonly through a patient portal, but sometimes it'll be a mix of portal and a brief telephone doing other things you might do, whether it's setting up some lab to be done and reviewing it, sending in a prescription, contacting some other care provider or having your staff do it. But basically you're consuming a moderate amount of time on behalf of a patient and maybe day one, you don't realize it. You might respond to a portal message and then it turns into a whole series of portal communications and a bundle of services, which accumulate to at least five minutes and many times 11 to 20, occasionally more. So again, this is billable. Comparable patient, again, let's say this constipation example, they send you a portal message after a month saying it's not helping. You trade portal messages over several days, deciding what further to do, more indication, patient's still not doing better. You decide to send a prescription, schedule a four-week follow-up later. But from all that work, about 12 minutes here, you create a note, you can build a 994-22 service and get paid for that extra work that you're doing that is accumulating in your inbox as tasks. So here are the codes. Again, there are some Medicare rules for it. It should be done through a HIPAA secure platform. It's for established patients only and should be initiated by the patient. And again, it's not linked to an immediate adjacent face-to-face or telehealth video visit. The reimbursements for these though are noticeably lower in the area of $15 to $47. So the majority of them would be 15 to $30. But keep in mind, when you phone the patient and have an actual phone discussion, the same duration of time, the reimbursement is substantially higher. So your provider should be encouraged to turn these into telephone services or if there's room in the schedule to schedule them for a visit or a telehealth visit in the near future. So you can actually boost this to the level of a significantly higher payment. Now, with all of these kinds of services, you have to be careful you're not overlapping with other E&M services being performed for the same time period. I won't go through all these other codes, but again, read the CPT rules if you're going to use these. There are two other types of services that came into being really during COVID-19 and seem to be permanent. And you can think of them as virtual check-ins, but I think they have relatively limited value and should be relatively few in number. One is for looking at images or recorded video submitted by an established patient, which you look at and you interpret and you kind of follow up with the patient, give them some feedback. And again, it's not just part of a related visit before or right after that. But the other is more like a quick internet call, more like that portal exchange. There's a G-code for it that's separate, but when you look at the reimbursement for it, it's not as robust as for other things. But let's say as an example, you have a patient who is getting gastrostomy fed. You see the patient because they come in because they've got inflammation, maybe cellulitis. You decide to use a barrier cream. There's no serious infection, but you want to get an image of the G-tube site from the patient a month later. And they send that to you, however they get it to you. You review the image. You may then make a quick call or send a portal message to the patient telling them, okay, site looks good. Just keep doing what you're doing. Follow up as needed. You can build G2010 for that service because you received imaging, you documented it, you communicated back to the patient. All of this need not take very much time. Somewhat similar to the portal service sequence that I went through, you could have a relatively quick communication from the patient a month after, and maybe they have improved with their constipation, et cetera. You respond back quickly by either phone or by portal. You're doing good. You don't need to change what you're doing. See us as needed. You can create a quick note and build a G2012 code for what is basically a fairly quick service on your part. And that's the check-in by the patient. So it's encouraging that, I mean, CMS wanted to encourage continuity of care and wanted to make sure patients have adequate access to physicians for follow-up. And so again, there are a few rules related to it, but they're relatively simple. But they also don't reimburse a whole lot. The imaging reimburses about $12. The virtual check-in, kind of internet portal, quick telephone, about $14. But again, comparably, a five to 10 minute telephone service reimburses a lot more. And of course, an actual visit, if warranted, also comparable amounts. So when appropriate, phone home, call the patient. If you think it's gonna take five to 10 minutes, then you have justification for using those telephone service codes for that encounter. If you think you can do it much quicker and easier without spending that much time, you may well be able to make utilization of these other codes or the series of portal message codes. And then finally, there are what are called electronic consultations. We're not making much use of these, but there are situations primarily within a large multi-specialty group that have access to the entire electronic record of the primary care doctor or the other specialty physicians, where you may get what otherwise might be a curbside consultation by telephone. Somebody calls you and says, hey, I've got this patient with this and such a problem. What do you think about it? Well, there is a way that the specialty physician can spend five or 10 minutes looking at the record and get back to the requesting physician with a verbal or written report. So you could just create something within the EHR, getting back to the physician who requested a curbside consultation. And there is a code 99446 for this. There are codes for longer durations of these services, but I think those would be very unusual to be doing and involve more work. But for example, a patient with poorly controlled diabetes, nausea, vomiting, frequent hospitalization that lives four hours away, the local primary care wants to consult with GI. They're trying to do a workup. They just want to make sure that what they've done seems appropriate. There's records that are either sent or available to you through your EHR that you can review, which clearly indicates what's been done for the patient. And you can basically create a short note that goes back to the requesting physician. And that is billed at the 451 level, the actual consulting physician, the PCP can bill at a level also if they spend more than 15 minutes preparing the case for your review. So occasionally this has value to the referring doctor, but it also is a service that can be performed, especially for rural outlying patients, preferably in practices that have a lot of sites and share the same medical record. Again, there are a few Medicare rules that relate to it. It can't relate to a service that's just immediately after a visit or gonna lead to one in the next couple of weeks. And the proper record keeping needs to be done. But these codes do exist and they do have some value, not quite that of an office visit, but for the five minutes plus of physician work for the specialist, $35, and by the referral doctor also about $35 for their work. So again, these codes exist and it may be that within your practice environment, this is something practical to do. I've seen this set up in university hospitals. I've heard of it being done in other medical settings. So what we've been trying to do as a tri-society is to be sure that telehealth services remain permanent after the pandemic. And so far we've seen successful, Medicare seems to be supporting them. We need some help by Congress down the line to be sure that these don't go away. We want payment parity for video and audio only if we can accomplish it. But what you're going to see in the future is there probably will be separate CPT codes for the audio only services. And the RUC is trying to establish appropriate value for these. We probably won't know much about these till next year or possibly the year after. We may say something in the proposed rule by Medicare about this coming this summer. But the hope is that we'll have adequate access for audio only services and adequate payment to make this sensible for us and make it something good for patients. So this is where we are. A good deal of this is covered in the references that I put here. And if you haven't paid much attention to these in your practice, take it home and get on with it. Look at some of these, decide how you can work these into your practices. And again, I'm happy to take questions about this either during our course today or feel free to mail me what is on your mind. Thank you very much.

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