All right, so we're going to kind of put this into play now to kind of make sure this all makes sense to you. So we're going to look at examples by medical decision making, and then we're going to look at examples by time, okay? We're also going to talk about endoscopic risk factors, because that is a big majority of your patients. So you have to determine, okay, is this going to be more of a level three, a level four, a level five? And again, I'm going to give you an example of each one of those. All right, case number one. We've got an established patient, okay? This is an office visit, established patient. Patient comes in, and these guys, these are just more for you looking at the assessment and plan and pulling out the decision making. I wanted to make it as easy as I could to kind of follow it. Just assume there's an interval, there's a chief complaint, and a pertinent history and exam documented, okay? So we're focused more on what am I doing, or what did I address, what am I doing about it, and what is this level? So assessment. Patient with IBS-C, which is stable at this time, continue current dose and frequency of amnesia, eight MCG twice daily, refill sent to the pharmacy, return in six months for reevaluation unless otherwise indicated, all right? So I've got this table where I pulled in problem addressed, data, and risk, okay? So for this patient, this is one stable chronic condition, which is low on the decision making table. So we've got the data, so that's minimal, and we have a prescription, which is moderate. Remember when I first started talking on my last talk, two of the three of these are required to support your level. Well, I don't have two of the same thing. I've got a low, I've got a minimal, I've got a moderate. So when you have it all over the place like that, you pick the one in the middle, which is low. If you look at your low decision making, follow-up office visit, that's a 99213, okay? I see a lot of these billed as twos. Sometimes though, I see these billed as fours, okay? So this is a three. One stable chronic condition, medication refill, all right? Here's another established patient. So patient has IBS. It appears under control at this time, despite increased stress factors, reports increased anxiety due to financial and work stress. Continue medications for IBS. I will increase amitriptyline dosage to 50 milligrams daily. She's requesting psychiatric counseling. I believe this would be beneficial for her. Appointment was made with Dr. X next week. Return in three months for reevaluation, unless otherwise indicated. All right, so I'm going to plug that one in. So this is not just a stable chronic, you know, hey, Sally, you're doing well, go away. Here's your refill, okay? No, this patient is experiencing progression or side effects of treatment of her chronic condition, okay? So that's moderate. Still minimal data, but we also, again, have moderate for prescription. So look, I've got two moderates right here. It is a level four when you have two of them in your decision-making. So this is a follow-up 99214. Look at a new patient. So we've got left, they've got new left upper quadrant abdominal pain. He has a history of a gastric ulcer. Primary care started the patient on Omeprazole with no improvement. I reviewed the primary care's records. Details are in the HPI. Patient's wife is here to provide me with more information regarding the patient's symptoms. She states that he also complained of heartburn to the point of making him nauseated. Plan continue current medication, Ventil as needed, and increase Omeprazole to twice daily. We'll order a gastric emptying scan with solids and liquids, follow-up in a month. All right. So we've got, this is more of an undiagnosed problem. We don't know what's going on. Primary care put the patient on the medication. It didn't help. Now we're doing our own workup, moderate. We also had moderate for data. We had an independent historian. We reviewed primary care's records and we ordered a gastric emptying study, okay? We also have prescription drug management. We have three moderates across the board. So this is night and day 99204. New patient level four. Here's another new patient. Chief complaint, acid reflux. Millie is a 48 year old female referred by Dr. MD. She has a history of duodenal ulcers 15 years ago. She has had new reflux symptoms in the past year and is on Protonix. Recently, symptoms have become worse with an increase of heartburn and indigestion, which keeps her up at night. Denies any dysphagia. She's never smoked and rarely drinks alcohol. So impression, symptomatic GERD. Plan, EGD to rule out Barrett's. The patient verbalizes understanding of the procedure. All right. So we've got a chronic problem with exacerbation, okay, which is moderate. We have no data. Hmm, what about risk? We're getting an endoscopy on them, on the patient, but that's all. We didn't say any risk factors. We didn't say anything. So that's low. So again, we've got three different ones. You pick the one in the middle, which results in low decision making, 99203. This is not a four anymore, guys. So, you know, our brains, you know, if we've been practicing medicine for years and we've been assigning levels based upon old guidelines, we kind of have it engraved in our brain that, oh, I do, I order an endoscopy, it's level four. No, no, no, no, not anymore. It's defined by risks to the patient. So let's look at an initial hospital visit. So this is a patient with a GI bleed, acute blevossanemia. So classic admission, okay, for GI. This is a 47-year-old male admitted with blood in the stool and significant anemia on labs, 9.5. He has a history of peptic ulcer disease and inset use. He takes ibuprofen daily for chronic pain. He describes blood as dark, no pain with bowel movements. The bleeding started yesterday, and since then, he feels very weak and fatigued. Or via systems, denies any fever, weight loss, or pain. We've got our past medical history of ulcer disease, chronic back pain, otherwise healthy. Family history is negative for GI diseases. Drinks socially, no tobacco use. Exam, constitutional, appears weak and pale, no acute distress. Vital signs were reviewed and documented, slight hypotension and an elevated heart rate noted. Guess GI is bowel sounds active, no rebound or tenderness. Cardiovascular, tachycardia, no murmur appreciated. Respiratory lungs clear bilaterally, skin appears warm and pink. All right. Impression, 47-year-old male with a distant history of peptic ulcer disease admitted with significant blood in the stool and acute blevossanemia. 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 and ulcers. Monitor hemoglobin closely and transfuse if there's a significant drop. I will start the patient on an IV PPI therapy. Patient is significant higher risk for this procedure due to the inset use and the peptic ulcer disease. All right, so I think we can all agree that this is acute condition that poses a threat to life or bodily function. We're not going to just let the patient bleed. We're going to go in there and figure out the source. That's high. We had a review of hemoglobin, but we didn't order any more labs or CTs or anything like that, so minimal. And then risk, urgent emergent endoscopy, high. Okay, so you're at a 99223 for those payers that don't accept consults or level five consultation. And again, that wasn't based on four review assistance documented and six exam elements, none of that. It was focused on your assessment and plan of care. All right, here's a hospital follow-up visit. We have a chief complaint, GI bleed, acute blood loss anemia, status post EGD. So this patient, same patient, we're rounding on them the next day. Subjective, doing well, had an EGD yesterday, which showed an active bleeding gastric ulcer, which was treated with an epinephrine injection. His hemoglobin increased to 10.5, so transfusion was not given. He is feeling better, more energy, no longer passing blood. Objective, patient looks well, color is good, no acute distress. Bowel sounds are active, no pain or tenderness. And we're in the impression and plan. Patient presented to the hospital initially with blood in the stool, which has resolved. We performed an emergency EGD yesterday, which showed an active bleeding ulcer, which was treated. Patient is doing well, stable. Continue to monitor hemoglobin. Continue IV PPI therapy. If he continues to do well, may be discharged tomorrow. I counseled the patient on NSAID use and ulcer risks. All questions were answered. All right, so for the follow-up visit, we've got a stable acute illness. So that in one day, that problem went from a life-threatening condition to stable acute illness, okay? That's low. We reviewed hemoglobin, which is minimal, and we provided the PPI therapy, which is moderate, okay? So we have low again. If you look to your decision-making table, low, a follow-up hospital visit for low is a 99231. All right, so let's talk about endoscopic risks, because that's, again, that's one of the many, many things that we do, but one of the most important workups we give on our patients. We do these procedures. We live and breathe endoscopy, okay? So I want to make sure that you understand the level that is supported with the different endoscopic workups involved. All right, so this first example is a level three, okay? So new patient presents with complaints of nausea, vomiting, along with epigastric pain. We'll schedule the patient for an upper endoscopy at the ASC, instructions provided, all questions answered. Okay, so our problem might have been moderate, but remember, we need 203. The risk is low because you're dealing with a minor procedure with no risk factors documented. Patient-specific risk factors have to be documented. That's 99203. Here's a level four. 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. Patient is at a higher risk for this procedure due to underlying conditions of CAD, diabetes, and severe morbid obesity with a current BMI of 46. All right, so this is now a four because I'm doing an endoscopy and I've identified this patient's risk factors that are involved. Number three, 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. Risks and benefits were discussed, all questions answered. This is a high-level visit. Not only am I dealing with conditions that pose a threat to life or bodily function, I'm going to perform a high-risk procedure on this patient. I've told you why. I've said it's major. There is no question whatsoever that this is a high-level five decision-making example. All right, so again, back to a can't say it enough, the more you put it in lay terminology, you just say it how it is, the better off you're going to be supporting those higher-level visits when they do come up, and they do. It's just sometimes it's like I can see it, I know it's there, but you didn't say it. And we always say if it wasn't documented, it wasn't done. And with the AMA specifically saying that the provider has to identify the risk involved, this is what needs to be documented. All right, so leading into our polling question, true or false? If the patient has chronic conditions listed in the past medical history and is having endoscopic workup, this automatically supports moderate risk for minor surgery with risk factors. Is that true or is that false? All right, false is correct. Okay, so that's the thing, guys. Remember, those that are auditing your notes or requesting your records from a payer's perspective, they don't do endoscopies. They don't have a clue what you guys do. They're looking at hundreds and hundreds and thousands of claims every day. All right, so if you don't say it in your assessment and plan as part of the workup involved, they may not give you credit for it. I can't assume, just like with the prescription medication talk that I gave you, just because it's listed up in the medication list does not mean you're managing that specific medication. You got to tell me. So just for risk factors, same thing. You got to tell me. And how do you do it? Those exact examples that we just went over. Okay, so make sure you pull those risk factors into your assessment and plan. All right, time billing. Okay, so we talked about what meets the requirement, like what you can count to support your time, what the time thresholds are for your levels of visit. So now we're going to show you how to document your time. Okay, so this first example is a patient that is a follow-up for a recent pancolitis flare. She was vacationing. She started experiencing severe cramping, diarrhea, bleeding. She went to the hospital there due to her severity of her symptoms. Since being treated at the hospital, her symptoms have improved and back to baseline. No changes in her past family social history. Review of systems, patient has occasional episodes of abdominal cramping and diarrhea, but this is her typical baseline. No other symptoms reported. Exam. Patient appears well, is pleasant, no acute distress. No abdominal pain, no tenderness, bowel sounds active. So impression, plan of care. Again, recap of the hospitalization. I have recommended her Remicade infusions be shortened down to six weeks from eight. This was discussed with the patient in detail in which she agrees. We'll order the new infusion schedule. Patient to follow up with me in three months or sooner if symptoms worsen again. I spent 15 minutes reviewing her records from Florida, 20 in history and exam, and an additional 10 documenting this visit and adding new orders in for her infusion. Guys, if you add that up, that's a 99215. That is a level five follow-up because you get to add up all that time. All right, so this patient by decision-making is not a level five. Okay, you're dealing with more of a, she's out and now stable, chronic condition. This is more of a level three by decision-making. But again, I spent a lot of time doing these things in the care of the patient. I documented. I can now bill a five. That's a lot, that's quite a bit of difference in reimbursement. If you look at your RVUs, your fee schedule for your different levels of services, you're talking anywhere from $20 to $40 depending upon, of course, your contracts with your payers, but $20 to $40 per level that you increase. So keep that in mind. You're not going to bill every patient by time, but when you get into situations like these, that's when you want to. Here's another one. This is actually a new patient. So we've got a pertinent chief complaint history and exam documented. This is a 53-year-old male presents for transplant evaluation. He is 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. Colonoscopy prep education provided to the patient and the procedure will be scheduled. Risks and benefits were also discussed. I spent 45 minutes in total time in patient encounter. Approximately 30 minutes spent with the patient. Communication was very difficult as he does not speak English. Communicated via translator over the phone. The remaining 15 minutes was spent in review of the patient's history and documentation of this encounter. That's a level four. Decision-making was maybe not even a level three because this patient really doesn't have any problems. It's just they're coming in to say, hey, I need my colonoscopy. Will you do it? No real problems here. So, again, this is a scenario where your time is going to trump your decision-making. All right, that is it for the guidelines and the examples. So, I think at this point, we are leading into our Q&A.

medical decision making

patient cases

data assessment

risk factors

time documentation