Kathy, I think you wanted this one directed towards you. So, the scenario is an outpatient setting here. Is it mandatory to route note to consulting physician to bill consultation and E&M? One of the guidelines in consultation services is there has to be the name of the requesting provider and there has to be a what, a report back to the requesting provider. So yeah, we definitely need to make sure that that is, let's put it this way, it has to be contained somewhere in that note. It has to be in the record, you know, and we know that, you know, Medicare doesn't accept consults and a good percentage of payers don't either anymore. But I think some of you that are listening in, and it's actually regional because some of Blue Cross and Blue Shield payers do accept consults and some don't. And I think one of the major, let's put it this way, one of the major payers that actually look at this is the Blue Cross and Blue Shield payer that does accept consultations. It's often that we've been told that practices have to submit documentation, and if they do not see that there was a report sent to the requesting provider, they will take that consultation away. So there needs to be at least something in your medical record, in your EHR that shows that a report was sent. Sometimes we don't see that. You know, so some of the things that when we do reviews, we make sure that the practice knows that if a consultation service was billed, that we also need to make sure that there is something in the medical record or something sent if we don't have access to their EHR that shows that there was a report sent back. Wonderful. Wonderful. And our next question is, can you share how providers should document procedures performed in the office? And the example they give is a hemorrhoidectomy, banding. I have providers who say, quote, unquote, banding complete. Is that enough to support a 46621? Oh, well, you guys are doing some head shaking here, so I think not. Yeah. You want me to tackle this one or do you want it? You can do it, Kristen, that's fine. So if you guys are doing hemorrhoid bandings in the office, just set up a template. That's the easiest recommendation. You know, you're going to have to, your EMR in the office is typically flows like visit format. So that's why a lot of these procedures get documented inappropriately because we just throw it in the middle of our exam. You can't do that. You got to have a separate hemorrhoidectomy template. We have to know risks and benefits were discussed with the patient. Patient agrees to the procedure. We have to have indications. And guys, document the grade of the hemorrhoid, okay? You got to document the grade. So yeah, that is, unfortunately, that is not enough. I would definitely work. And if you're not sure on templates, you usually have one provider around that's template savvy or reach out to your IT and create that template. But that's our, that's my recommendation. So they had given us one example, the hemorrhoidectomy banding. Are there other things that might be done in the office like that you can think of that you might want to form other templates for, or do they really need to think about how the practice is doing that? Yeah. I mean, there's another one too, sigmoidoscopy is sometimes done, anoscopy is also done during sometimes the initial visits. And again, like Kristen said, sometimes we just see that anoscopy was done in the physical examination. But if you were trying to bill for a procedure, especially anoscopy, a lot of times is done in addition to a visit, there needs to be a separate procedure note, especially if you're trying to support modifier 25, which is a visit on the same day of the procedure. So it's, I mean, that's a good question, Eden. We definitely, and I think sometimes with some of the electronic medical record systems, it seems that there has to be a visit note. They can't just do a procedure note, which baffles me. It just seems like they're in the office setting, it's just like, there has to be a visit note to support any type of scheduled encounter that day. So sometimes I think some of the providers are kind of perplexed with this. And Dr. Littenberg, can I speak on this one, because you know, there's been several types of EHRs out there that also don't, are not, let's put it this way, procedure friendly in the visit sector, in the office. Yeah, when there's really no way to kind of insert a note for a separate procedure, I mean, basically just have to set off the procedural description in a separate paragraph someplace. That's probably the best way. But when you're trying to justify a 25 modifier, you know, it should also be clear in the documentation that the decision to do the procedure was based on the symptoms, that it wasn't a preplanned procedure. You know, a patient here for anoscopy is not going to justify a 25 modified visit. But if, you know, a patient being assessed for rectal bleeding, you describe it, physical exam is pertinent, decision made to do anoscopy, and then you describe the anoscopy. You have the basis for billing both. So there are a lot of EHRs that do have a separate intervention section or something of the sort that, you know, you're opening up a procedural note, it may still be part of the same page or two, or it may be a separate template you can open up. Just depends on your EHR and how you use it. Thank you. Thanks for answering my additional question. So next question is, what if the chief complaint is just missing? What do you do? Um, well, at that point, it's not billable, it doesn't, you know, you have to establish medical necessity, you can definitely go in and have the provider and then the report to include that chief complaint. You know, if your HPI starts off with here for this, I'm going to give you credit for it. But if it's just, I was actually looking at a note yesterday, and there was no chief complaint. And it was just like, they just started talking about know this, know that, know this, I couldn't even figure out why the patient was there until I got down to the assessment. So that's where it's going to be an issue. So I would just make it a hard stop. That's what a lot of practices have implemented. I see it mostly missing on hospital follow ups. I think that's where the issue is. And the thing is, if your template doesn't hurt, like they don't force you to add it, probably not going to add it. So that's what I would do. I would just have the provider go back in a minute or just look in your HPI and make sure that something is there that we're seeing the patient for this reason. I think we've gotten some feedback from some of the providers on that this is all come on. I can't even figure out why I saw this patient. It's in the assessment and plan that like what Kristen said earlier, the assessment and plan is decision making. All right. And sometimes it is redundant. You know, pancreatitis is the reason you're doing a follow up in the hospital and it's the same thing you're managing on the patient. But sometimes there's things that change on a daily basis. And so, you know, bottom line is there has to be a chief complaint. And we've seen where the payers have audited and come back and denied the claim because it was missing the chief complaint. So I mean, they're kind of looking at structure, you know, so if there's no chief complaint, they go, OK, no reason. So yeah, it is very important. Dr. Littenberg, can I ask you to to kind of support our folks out there for the physicians who say, oh, you can figure it out? What would you say to your colleagues in terms of of proper documentation and being supportive of those people who come to them with these questions and say, hey, the chief complaint is missing? Well, it doesn't, especially in a hospital setting, commonly, you know, there's not a separate field for chief complaint. You don't have to put one in. But, you know, the opening to your interim note should typically say, you know, follow up for something, whatever it is. And that could be F slash U P A N C. That's enough. Follow up pancreatitis. Then you describe whatever the interim history is for that day and then the data and then your assessment and plan. So it can be very simple, but it should the note should lead off for why are you there? You know, that that kind of establishes a medical necessity. You know, if you just say, you know, patient stable, no new problems, and then you go down to pancreatitis and your assessment, it's really not clear why you're there. And then there's no chief complaint there then. So it doesn't have to be complicated. And our next question, is there a need for a review of systems slash physical exam or a minimum requirement when performing a non E&M visit? And for example, they say a screening colonoscopy. Oh, okay. The next segment actually is the screening issue in the visit prior to screening. Okay. This is where you're going to have any. And I think that's probably the question. You still have to have a pertinent history on a pertinent exam if you're trying to build that visit. First of all, Medicare will not pay for the visit prior to screening. Okay. Second of all, some payers will. All right. And part of the Affordable Care Act allows for a visit prior to screening colonoscopy and there's a specific code for that. It's S0285. Now, you still need to have a history. All right. If the patient has any family history, if they have any symptoms, blah, blah, blah. We all know that some patients still have symptoms and obviously they're sent to us for screening, but they have symptoms and we have to rule some of that out. But the thing is, we also need to do a pertinent physical exam. That's part of the visit component. So yes, it's payable by some payers and there should be a pertinent history in the exam regardless when you're billing any type of visit. The procedural date does require some degree of history, which may just be indication. And pertinent physical exam indicates stability of the patient's suitability for the anesthesia that's being planned. That's part of the medical necessity of a procedure. It's required as part of ASC or HOPD. But each facility can kind of set what its standards are. So it doesn't have to be a complete physical exam, but there should be some requirement and reflected by the template of at least the limited pertinent physical exam and it needs to be filled out and that needs to be part of that day's note. So that's typically how templates are put together for a pre-procedural H and P related to a procedure. So there needs to be something there, it doesn't necessarily need to be very complex. Patient here for screening colonoscopy, average risk factors, lungs are clear, heart normal, abdomen soft, something fairly simple, and then the vital signs there. But the procedural day does need to have some of that information. Our next question is, if you ordered three unique tests, does it count for three points? It counts for moderate data components. So we don't really go by three points or two points, but it is in the category of moderate. So if you do order three unique tests and those are defined, and we know they're three unique tests, that is moderate for data. Yep. Thank you. And if you are seeing a patient the first time in observation and you are not the admitting physician, would you bill an initial visit or subsequent visit? I actually have this in a talk coming up this afternoon. So I'm actually going to address this main issue. Number one, it's unfortunately not a one answer, it's a pair issue. Two, like for Medicare, for example, they clarified, most of the Medicare contractors clarified that if you are a specialist doing a consultation for an observation patient, well, you can't bill the initial, you can't bill a consultation to them. So they look to, they reference the office visits, 99202 through 215. So then you're going to look to see, have we seen this patient in the last three years? So that's really going to be determining it. And a lot of payers are like that, but again, it's payer specific. And I've got some examples coming up. Wonderful. So more to come. That was just a tease. More to come. Can a screening colonoscopy be considered during a clinic visit when calculating the medical decision-making? So I assume this is an example of patient coming in for GERD, but oh, by the way, they're 45 and need their colonoscopy. I mean, your GERD is going to support the level anyway. Your GERD or whatever you're addressing is going to support that level over your screening colonoscopy, the fact that, hey, you're 45, you need your colonoscopy. If it's a screening, if it's a visit prior to screening only, then you're back to what Kathy kind of commented on, the SO285, which is a flat payment. Any other comments on that, guys? If the patient is actually truly coming in for screening and the payer does not accept that as code, that's still considered just minimal, straightforward decision-making and the highest it would support would be level two. So, you know, it's not really going to affect your decision-making. And like Kristen said, if you're seeing a patient for other conditions, that's going to supersede the screening. Yeah, there will be occasional exceptions. You have that scenario, but the patient is, let's say, diabetic and on a ozempic drug and they're on Eliquis for their atrial fibrillation, you know, you have to deal with those issues in the planning for the procedure and, you know, somewhat changes the risk profile, counseling, et cetera. So, that might add, but that may be more in terms of time than in terms of medical decision-making. Just depends on the circumstances. Those situations will come up sometimes. Okay. And our next question is, can you bill new patient 99203 visit instead of pre-visit for colon cancer screening SO285 when you also address obesity and perform counseling? I think Dr. Littenberg pretty well just answered that one. You know, if you're managing the patient's condition, the medical conditions, that actually does pull into that scenario. And it might also potentially increase you to level four, just depending upon how many conditions you're managing, you know, into any type of prescription management that day. You know, so actually that came up, I was in a practice this week and one of the physicians was asking about, you know, what if we tell the patient to stop the ozempic and this is not screening colonoscopy, this is EGD, you know, if they want to stop the ozempic a couple of days before because of the increased risk of gastroparesis, et cetera, and food in the stomach. You know, so yeah, if you are managing patient's medical condition, you know, depending on why they're on the ozempic, you know, we're seeing patients on ozempic just for weight loss, you know, but a lot of times it's a combination of besides weight loss as well as their diabetics. So, you know, if you're managing their medical condition, it's potentially higher even than level three. You know, it's all based upon the documentation, the medical record. Okay. Fantastic. Can you bill an NP office visit for screening colonoscopy consult without any other supporting ICD, just screening colo? What do you think, Kristen? I think we address that. That's going to be the SO285 for the payers that allow for that. For Medicare? No. Medicare is not going to cover it. If it's strictly just visit prior to screening, nothing else addressed. Once you got something else, you can bill that E&M visit to Medicare, but yeah, you're looking at SO285. We'll be going over that again in more detail later. Right. For the risk of procedure, does it matter if anesthesia is providing sedation or the gastroenterologist? For the risk of procedure, does it matter if anesthesia is providing sedation or the gastroenterologist? Personally, I don't think that would matter. I mean, there's procedural risk levels based on the patient characteristics, and that doesn't really matter who's providing the anesthesia. It may be a justification for why you want anesthesia and want monitored anesthesia care, which is usually propofol. that should be clear. This patient requires propofol because of ASA level three or being more specific about their conditions. But it's still your assessment of the patient's risk, even though the anesthesiologist will also assess the patient's risk separately. It's kind of like you killed two birds with one stone on this one. It's kind of like you're supporting your potential for minor surgery with risk factors or potentially major surgery with risk factors, as well as supporting the need for MAC too. So, I mean, not just for the monitored anesthesia here, but you're also supporting your risk associated with the procedures too. And this is just a sidebar. We've gotten some, and I'm gonna talk about anesthesia a little bit later. But the thing is, is we're starting to see more and more commercial payers out there not approving MAC unless the patient's ASA three. And this was just actually released beginning January 1st. Couple of Blue Cross and Blue Shield payers basically have said that, that they will not accept or not pay for monitored care unless the patient's ASA three status. So Medicare has kind of, some of the Medicare policies out there also have stated that the patient has, actually Medicare and Novitas is one of the payers actually that has this huge 24 page LCD that has all of the list of approved diagnosis codes on it. And most of them do have ASA two, but most of them are ASA three status. It's really interesting. I was just contacted by a nurse. They had just been surveyed by AAAHC and they got a consultative recommendation to switch to MAC, which our chief policy officer, Lakeisha Mann, I found rather interesting based on what you said that they would receive that recommendation. Our next question is, can you use a screening diagnosis code? Can that be used on an E&M visit? Okay. Not as primary. Back to the same scenario, the visit prior to screening. So, I think my recommendation is if you know the payer, they have that visit consultation prior to screening SO285 in their preventative colonoscopy policy, which you can find many of them online, I would recommend you build the S code with the screening. We do have some payers that will allow you to bill an E&M visit, but again, you're thinking about more of a low-level visit. Medicare, no. I think a sidebar to this too, and I think it has to go with a question that was asked earlier. Kristen mentioned too, that if you're addressing like GERD and screening, you don't want screening in the first position. You want GERD in the first position. And I think that's kind of the, you have to watch that. And I mentioned that earlier when I was talking about ICD-10 is you really have to be careful that primary diagnosis is what the payers are looking at as the major reason for the visit. So, if you're addressing IBD and you're addressing GERD and you're addressing cirrhosis and you're also doing screening, screening is not primary, right? And that can throw that whole visit out the door. So, like I said, all of your providers need to be aware that what they put as number one in the assessment and plan, that is what goes out on the claim. All right, so I recommend that, and you can set up parameters in your software, in your billing software system, that if that comes as a primary, that should go in somebody's queue. Or it's like, whoa, wait a minute, this should not be a primary diagnosis. All right, so again, depending upon what your policies are in the office, some practices look at everything before they go out. Every visit note, every office visit note, every inpatient note, every endoscopy report, it gets looked at before it goes out. And you can catch that stuff, all right? But if it doesn't get looked at and that stuff goes out, what happens is the payers come back and say, hmm, not a valid reason, all right? Not a covered diagnosis, et cetera, on this. And that costs your practice money. Any type of denied or appended claim costs the practice at least $35 per, let's put it this way, the guidelines that MGMA out there pretty well looks at that. And I think $35, and I think we get questions, oh my gosh, well, how come it costs that much? Well, first of all, it's called overhead. You gotta figure out why it's denied. Denial reasons, oh my gosh, there's hundreds of them, all right? And sometimes you get three or four or five denial reasons on an explanation of benefits back and you gotta figure out why. You know, why this claim got denied in the first place. So, but one of the primary issues is putting down screening family history, et cetera, as a primary, when the patient has other symptoms and other medical conditions that you're addressing. And I, one comment, just so everybody kind of knows about this is because we've been in places where we're in offices, we're looking at their EMRs, we're looking at how they're assigning levels and diagnosis. And we often find they have no idea that diabetes is going out as the primary diagnosis when the patient came in with epigastric pain, you know what I mean? So the primary diagnosis on a claim is very, very, very important. And you have to make, you have to kind of do a double check on that. If your providers are responsible for assigning their levels and assigning their diagnosis codes, someone's gonna have to watch to make sure those diagnosis codes are getting sent out appropriately in the right order. Just like you said, you end up with screening primary when other things are addressed, or you'll, you end up with the diagnosis, like I said, a non-GI diagnosis primary on the claim. So, and that can, again, just kind of be a red flag. On the inpatient side, I think we see this too. You know, there's so many times where the patient is being, you know, multiple medical problems in the hospital, you know, but they're being managed by pulmonary versus renal versus ID, et cetera. You know, so you wanna make sure that the conditions you are managing go out as the primaries. And some of those other conditions support the complexity, you know, but if you're not managing them, they should not be primary. So we have a raised hand. So Eric, I see your hand is raised. I've just clicked a button to allow you to talk. You might have to unmute yourself, but please feel free. Yeah, great, we can hear you. I had a couple of questions. One is how to appropriately attend a fellows note. I work in an academic center. And the other question was, I thought I had heard you'd say like reviewing other consultants notes. So like if you're a gastroenterologist reviewing a cardiologist note, and does that count as external review or does it have to be literally from a different hospital? So as far as the record review goes, it's just someone else's chart. So it's someone else not in your practice. So it's not pulling up your own chart. If it's an external note or part of the hospital, whatever, as long as you state, you know, I reviewed cardiology XYZ's note and you give the pertinence, then that's definitely, that's fine. That's supported. And then the fellows note, my understanding was that, so my understanding was that you have to say that one, you've discussed it and examine the patient and then agree with the assessment and plan. That's it. So you can like set up, you can actually set up like a teaching template to add an addendum. And again, it's, I evaluated the patient. A lot of them, you know, I spoke with the fellow about the care plan. I agree with the management as above. A lot of times we recommend you just put in your own personal observation if there's a difference, you know? So one big thing that Medicare came out with, this is several years ago, but they made a big point that, you know, if your fellow admitted the patient in the morning and you round and see the patient in the evening and there has been a change of status to that patient, just comment on that. So you would put your, I saw an evaluated, I agree. And then put another line with your personal observations. That's best practice. One thing, just while we're on this topic, if you end up having like a late consult, so fellow gets called at 10 p.m., you don't do your addendum till the next morning, make sure that you specify in your addendum and you saw that patient because we bill by the date of service of you. We don't bill when the fellow sees the patient, we bill the date that you see the patient. Thank you. Yeah, most hospital templates will have some kind of a teaching note that you can insert fairly easily. Otherwise work with your IT folks to get it set up. It'll be there. Fair to say guys that we'll be talking more about the split shared visit documentation when it comes to kind of how do you document medical necessity to substantiate? That's the main part of it. Yeah, so I'll leave that for later. Thank you, Eric. Appreciate those questions. Our next question that came in was for a general gastroenterologist. And this person primarily is in an outpatient practice. Do you have a sense of what percentage of our bill should be level four versus level three? By recent benchmarking statistics. All right. And remember that these are always a year behind. Okay, so but the last part of it on the new patient visits, 50% level fours, 36% level threes, 6% were level fives. Now, remember, that is a distribution of what has been submitted as a GI. All right, that doesn't mean that's accurate for you. You know, so everything rests on your documentation to support medical necessity. These benchmarking statistics are more for payers to determine, huh, you guys bill 74% level fours. So maybe we need to look at your notes because you're way above the norm of the normal of the average GI. That doesn't mean the average GI knows how to bill. All right, so that's kind of where, you know, Kristen was talking about medical decision making. You know, this kind of just gives the payer an opportunity to look at this and go, huh, you're an outlier. So maybe we need to look at your notes. Now, it's looking at the office side as far as follow-ups go. It's 43% level threes and 46% level fours. So it's almost so close. But again, those are just statistical and that may not be appropriate for you. All right, and also depends upon the type of patient that you're seeing, you know, and where you practice and whether or not your patients are compliant with certain things as well. So, you know, as long as your documentation supports the level of service, it's accurate for you, right? Yeah, and I'm actually gonna touch a little bit more on that too in one of my afternoon sessions too, as far as benchmarking and how you need to kind of respond to some of those letters that you get or requests that you get, things like that. But, you know, my- Okay, so this question just came in and it follows up on this. I'm sorry, Dr. Littenberg, were you about to say something and I talked over you? That's okay. I was gonna add that historically, there was a much higher percent of level fives submitted by gastroenterologists back when E&M code in the 1990s was embedded with the current set of codes and then the documentation requirements. The documentation requirements that CMS imposed made it much harder to substantiate a level five and put much fear about auditing in the minds of many specialists. And so the amount of GI coding at level fives fell dramatically, even though we weren't seeing less complex patients. And when I'm teaching on this subject, I try to emphasize that we should be billing for the complexity that we actually do. And now it's a lot easier to document up to that level. My belief is, but there's still a lot of hesitancy to bill at that level, fear of audits, whatever it is, laziness at putting in the documentation. But I think we're still way under coding for what we do and the kinds of patients that we see. And you don't have to have a specialty practice of seeing only complex IBS patients in a university center or complex IBD patients that have failed five therapies to be billing these patients at level five. So again, if you're doing it right, you shouldn't be afraid to be billing at the higher level. And we'll come back to this over and over later today. So the follow-up question was, are the providers responsible for picking their level of service or should the coders be doing that by themselves? I think that's more up to your practice. So we've seen a variety of this. We've seen most of the time, unfortunately in the office, especially office setting, you've got so much productivity and not enough coders that oftentimes the providers are left responsible. We've got other practices where they audit a hundred percent and then we've got some practices where the docs say you do it, you pick the level. You go ahead and then there's other ones that say, hey, if you change any of my levels, you need to communicate that with me and why. So it's a variety that we see. I mean, ultimately the providers are responsible for the levels assigned to the claims. And if you're making them responsible, you should be educating them and giving them feedback on this because I think that's what Dr. Lindenberg was saying is so many, we see that GI undercodes. And I think it's kind of a fear or they just don't understand. So they feel safer billing a lower level of service than this. And ultimately you guys are managing highly complex patients, but it's up to you guys to document that. All right, but then it's also, you have to be, there shouldn't be a fear. There shouldn't be a fear of assigning a higher level service as long as your documentation supports it. Another common reason I think for undercoding is in the managed care environment when we're getting authorizations for our visits, they're often authorized at a level three and then the providers just feel, okay, I'll fill it at a level three. That's not appropriate. That really isn't appropriate. You're billed at the level of complexity of what you've done and deal with the managed care entity and try to change your contract so that they're more permissive of billing at higher levels or paying you at higher levels if that's what your practice is. Okay, I'm going to sneak in one more question before we go to break. We had received a few questions ahead of time and I think one fits this segment, but Kathy and Kristen, you'll tell me if I'm wrong on that. Someone had asked, please confirm that the FS modifier should be used on split shared services furnished in the hospital setting. They write inpatient and slash office-based surgery as Medicare is highly surveying these visits for correct reimbursement. Is that appropriate to- So I have a split share talk coming up and yes, FS modifier, if you are seeing a patient as a shared encounter in the facility, you have to identify that service to Medicare with an FS modifier, regardless if you're billing under the NP or the doctor, it doesn't matter who you're billing it under, you have to identify that it is a shared visit. It wouldn't apply in the office. There is no shared services in the office setting anymore. And I think Kathy, you mentioned that this morning. I have a question before we go to break, which gets back to the talks this morning. Physicians, not uncommonly, including myself, we set up the next day's visit notes. Now we kind of review our charts. We set up maybe the first paragraph, why the patient's coming back, but whatever was pertinent. And then some of us sort of finish our note the next day, but we want to build based on time. Any suggestions? Unfortunately, they state very clear, the AMA states very clear that you have to spend that time on the date you see the patient. I'm sorry. And that is not my rule. Don't, I am just the messenger. I don't understand that, but if it's all part of your patient's care and you're monitoring how much time you spend, you would think, but they make it clear, gotta be done on the date of service. And yet the valuation through the RUC and what CMS agreed to, takes into account pre-work after work, which is not the same day. Right.

FS modifier

split shared services

hospital setting

shared visit

office setting

next day's visit notes

documentation