All right, thank you, Dr. Sun. That was a very interesting point of view from the physician regarding E&M documentation, and it kind of makes me feel better as an auditor whenever, you know, you get to hear providers talk about it at their angle and the importance of your assessment and plan and getting that chief complaint specific and just making sure that document makes sense as well as you go along, stressing those importance. So I am going to now take you through, so we kind of delve into the guidelines. And there's a lot, you know, there's a lot of aspects related to decision making as we just went through. So now we're going to kind of put all those guidelines into play in some clinical examples. And I'll kind of explain some things to you along the way and give you some more tips as well to really make that assessment and plan very clear. And I think that's really where your main focus should be. You know, your notes should flow. You definitely have to have a chief complaint that's specific and that's related to the reason you're seeing the patient today. And you have to have that good interval history. Again, no more bean counting, review of systems, exam, etc. We just need that note to make sense. But the main, main focus is making sure that you get all of those assessment and plan elements documented, all of your data components documented within that note. And then again, prescription drug medicine, we're going to talk about that. So first, again, we are going to kind of go through the decision making aspects of it first. Okay, so we're going to take a look at some new patients, some established patients, some hospital clinical scenarios. And then we are going to take some time discussing endoscopic risks. Because you know, obviously as a GI provider, most of your patients, several of your patients, you're doing endoscopy workup on them. And so it's very important to kind of align your level with that patient and that clinical status of the patient. So whether they're just a normal, healthy patient versus a complex patient versus an emergent patient, and kind of what needs to be documented within that assessment and plan to support the higher level, whether you're documenting by decision making. And also, we're going to look at examples by time. So you know, we always tell providers when your decision making may support a lower level, but it's kind of one of those things like you can't get out of the room. So when time should factor into your visit, and when should you document it, and how, very important, how time should be documented within that note. All right, so the first one, we're going to look at an established patient. All right, and you, I know you guys get these patients quite often. You know, it's your typical GERD patient, they're doing well on their regimen. They need a refill. You're really not spending more than five, 10 minutes with the patient, straightforward. This does happen, doesn't happen all the time. Usually patients will come in and they'll complain about something else, or maybe they have something new going on. But this one is just your straight, stable chronic condition. So this patient has a long history of GERD, which is stable at this time. Plan current dose of pentoprazole 40 milligrams daily, refills were sent to the pharmacy, return in six months for reevaluation unless otherwise indicated. All right, so again, this is pretty well a straightforward assessment and plan. You're going to break down those decision-making components, those three components, complexity of problems, data, and overall risk. So in this scenario, you have one chronic stable condition. And on that decision-making table, that sits in the low complexity. You had really no data here, nothing to be worked up, no prior records. And then you also have prescription drug management. So we documented the name, and the dose, and the continuing, et cetera. All right, so that's moderate on your table of risk. Well, the problem with this is, and I think sometimes providers, if you don't know that two of the three of these components support your level, you might go, oh, this is a level four, because I refilled medications. No, it's not. You have to have two of the three. So in this scenario, we have a low, we have a minimal, we have a moderate. So which one do you go with? You go with the middleman, you go with low. Okay, so this visit overall is a 99213. Prior to these changes, the majority of the time, this is going to support more of a two and not a three. Okay, so there's a lot of scenarios where our level twos now kind of become level threes, but like a lot of our fives become level fours, and hopefully that kind of evened everything out. All right, now let's take a look at another chronic issue. All right, so this is still an established patient. This patient has IBS. It is under control at this time. However, the patient notes increased stress. She reports increased anxiety due to financial and work stress. So the recommendation is continue medications for IBS. I will increase amitriptyline to 50 milligrams daily. She's also requesting to see a psychiatric counseling, and I believe this would be beneficial for her. Appointment was made with Dr. X next week, and then I'm going to have that patient come back in three months. All right, so this is a little different. This is not just a stable, chronic, here's your meds, go away scenario, all right? Now you're dealing with some progression or side effects of treatment. The patient has stress, anxiety, which obviously can increase that IBS issue, okay? So we're not dealing with a chronic stable. This is moderate for your complexity of problems addressed. We still had no data here to factor in, and we do have prescription drug management on this example. So here you have the two moderates. So again, between the two of the three components, on an established patient, this would be a 99214. All right, here is a new patient, okay? So this patient presents with new left upper quadrant abdominal pain. He has a history of a gastric ulcer. Primary care started the patient on a Meprizol with no improvement. I reviewed 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 complains of heartburn to the point of making him nauseated. Plan, continue current medications until as needed and increase a Meprizol twice daily. We'll order gastric emptying scan with solids and liquids, follow up in a month. All right, so if you break this down into that decision-making table, this one you're kind of dealing with an undiagnosed problem, uncertain prognosis. You know, patient has a history, but we really don't know where this is coming from as far as, you know, the current issue. We have to work the patient up. We're doing a scan, emptying scan, et cetera. So that's moderate. We have some data components here. Independent historian, and I know Dr. Sun commented on this. This is very important. I think you guys do this or have this more than you document it. So independent historian, you've got spouse, you've got, you know, brother, sister, aunt, uncle, whoever it is, providing further information that the patient cannot provide. Whether again, they're a poor historian or, you know, they just aren't really elaborating on those symptoms, maybe they have dementia, et cetera. So very important to get that into your documentation because it increases that data component. So again, we've got independent historian. We also ordered a test. We ordered gastric emptying study, and we also reviewed outside records. And again, the summary was in the HPI. We were just focusing more on that assessment and plan. So moderate there. And then you've got your third component of prescription drug management again, which is moderate. So actually all three components were met for moderate, and this is a new patient. So again, this is going to be a 99204. Here's another new patient, change in bowels. Donald Duck is a 39-year-old male referred by Dr. MD for change in bowels. Change in bowels started a few months ago. Prior to this, he's had very normal bowel patterns. He now has several loose stools a day, and then he becomes constipated. He denies any blood in the stool or abdominal cramping. He drinks socially, does not use tobacco. Impression, change in bowels. We're going to order a colonoscopy to rule out microscopic colitis and IBD. If colonoscopy is normal, recommend the patient to start a trial of IBS medications. The patient verbalizes understanding of the procedure. Okay, so this is again one of those new problems with uncertain prognosis. I'm going to go back to that slide and show you, just kind of point that out. Differentials. Differentials is very important, and it's a good component to support that kind of, you know, the patient was sent to us with these symptoms. We really don't know what's going on with them. We need to do our own tests, procedures, et cetera. So very important for you to list your differentials. It kind of supports your thought process as to what you're thinking. It also supports maybe why you're going to go in and do biopsies or, you know, what maybe you're going to order, et cetera. So very important. So here it's, you know, to rule out microscopic colitis and IBD. So very important for you to put your differentials in. So on this one, again, we've got moderate for complexity of problems. There really was no data here. And then the risk goes into that procedure that you're ordering for that patient. Well, this is considered minor procedure. I think most of you GI providers would agree that, you know, what's the difference between minor and major? It's easy to say, well, there's a global here and there's a global there. But that's not necessarily true on all aspects. I would say definitely our procedures, basic upper lower endoscopy are really around the minor surgery category. Obviously, if you get into more advanced or very complicated cases, that could definitely bump that up into a major surgery. But it's very important for you to document if you are ordering any endoscopic testing on a patient that you document, you know, the severity and all that. And we'll get into that in a few slides when I talk about the differences between the low, moderate, high risk when you're doing endoscopy. So for this patient, though, we just say we're going to get this. We're going to get a colonoscopy. There was no patient specific risk factors documented, et cetera. So in that case, if you look at that risk table, it sits at low, minor surgery with no risk factors. So again, looking at this, you've got a moderate, a minimal, a low. The middle guy is low. And on a new patient, this would be a 99203. Let's look at initial hospital visit. Okay, this guy has, this is a classic. This is kind of one that you guys see a lot, and it has to do with your GI bleeds. So this patient presented with GI bleed and acute blood loss anemia. He was admitted with blood in the stool and significant anemia on labs, 9.5 hemoglobin. He has a history of peptic ulcer disease and NSAID 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. So denies any fever, weight loss, or abdominal pain. He's got his past medical history of peptic ulcer disease, chronic back pain, otherwise healthy. Family history is negative for GI diseases. Social history, drinks socially, no tobacco use. Examination, appears weak and pale, no acute distress. Vital signs reviewed and documented, slight hypotension and an elevated heart rate were noted. Bowel sounds active, no rebound, no tenderness. Tachycardia noted, no murmur appreciated. Lungs clear bilaterally. Skin was warm and pink. So your impression and plan, 47-year-old male with a distant history of peptic ulcer disease was admitted with significant blood in the stool and acute blood loss anemia. He is noted to have mild hypotension on exam. He does admit to daily NSAID use from chronic pain. Plan for an urgent EGD to look for source of bleeding given his history and chronic NSAID use. Monitor hemoglobin closely and transfuse if there's a significant drop. I will start the patient on IV PPI therapy. Patient has a significantly higher risk for this procedure due to that chronic NSAID use and peptic ulcer disease. All right, so for this one, we have more of an acute condition that poses a threat to life or bodily function. I mean, you know, the patient has an active bleed. All right, and if we don't intervene immediately, obviously that patient would not have a good outcome. So that is high on your decision-making table. Have minimal for data. There was one lab reviewed. And then we have an urgent emergent endoscopy, which is also high on the table of risk. So this is overall a high-complexity patient. So depending upon your payer, some payers, again, accept consults. If it's a true consult, consultation requirements were met. You're going to bill this as a 99255. If it's Medicare and those that follow Medicare, it's going to be that initial hospital visit, 99223. Now, take a look at the same patient. And we're seeing them, let's say, the day after the scope. Chief complaint, GI bleed, acute blepharoplasty, status post-EGD. Patient is doing well. He has an EGD. He had an EGD yesterday, which showed active bleeding of gastric ulcer, which was treated with epinephrine injection. His hemoglobin increased to 10.5, so transfusion was not given. He's feeling better, more energy, no longer passing blood. We've got constitutional, he looks well, color's good, no acute distress. Bowel sounds are active, no pain, no tenderness. So patient presented to the hospital initially with blood on the stool, which is resolved. We preferred an emergency EGD yesterday, which showed an active bleeding gastric ulcer, which was treated with epinephrine injection. Patient is doing well and stable. Continue to monitor hemoglobin. Continue IV PPI therapy. If he continues to do well, he's going to be discharged tomorrow. I counseled the patient on NSAID use and ulcer risks. All questions were answered. All right. So if you look at this one, even though the patient literally just had an active bleed, we treated the bleed. He's back to new. New patient again, right? No issues. Doing well. Probably going to be discharged. So you took that complexity from a life-threatening condition to now this is a stable acute illness. That's low. We had a review of hemoglobin still, which is minimal. And we did have still that IV PPI therapy going on, which is moderate. But the middle guy is low. If you look to the decision-making table, that is N99231. And I guarantee you most providers would probably have billed this as a two. It's definitely not a three. Okay. Keep in mind, I think, you know, when Kathy and I do audits for practices, the 99231 through 233 are, I feel like they kind of get left on the back burner. And that's where we see a lot of high error rates in the levels of visits. So just making sure that, you know, yes, the patient just had a bleed, but he's stable. He's doing well. Now, note that I also counseled the patient on inset use and ulcer risks. So while I leveled this by decision-making, this might have been another good example of maybe the time that you spent supported a higher level visit. And again, I will get into a couple of those clinical examples here in just a bit. So just keep that in mind, making sure that you understand the requirements of not only your office visits, but your hospital visits as well. And guys, it's easier because we're following the same decision-making table for whether you're seeing the patient in the office or the hospital study. This segues into my polling question. The following statement supports moderate risk for prescription drug management. Continue current medications for GERD, true or false? All right, so 36% say true, 64% say false. Okay, false is correct. And I see this a lot when I do reviews, is continue current medications. I don't know what medication you have the patient on. It could have been an over-the-counter medication. So over-the-counter medication is more of a low risk, but prescription drug management, obviously, is that moderate risk that we looked at. So very important, guys, when you are continuing prescription drug management, name, dose, all that information needs to be documented in your assessment and plan. As auditors, I cannot look at your medication list that the patient has and assume that you prescribe those medications. And a lot of times patients are on multiple medications and not just for a GI-related issue. So if you are the one managing that medication, whether you're starting it, stopping it, refilling it, whatever it is, making sure that you document that very clear in your assessment and plan. All right, so let's now take a look at endoscopy risks. Because again, you know, that's kind of one of your main workups is upper, lower endoscopy, etc. So we get this question a lot, is how do I document, how do I relay risk factors? What does this mean? What is patient-specific risk factor? What is procedure-specific risk factor? So we're going to kind of show you the difference between a low risk, a moderate risk, and a high risk in regards to endoscopic workup on a patient. So this first example, new patient presents with complaints of epigastric pain and bloating. Differentials include GERD, ulcers, gastritis. Plan will schedule the patient for an upper endoscopy at the ASC. Instructions provided to the patient, all questions were answered. Okay, so if you're looking at the risk, this is going to be low, 99203. So even though your complexity of problems is moderate, that undiagnosed problem, the risk is low. Remember, it drops that level down because you have to have two of the three components met. So again, this is a 99203. Clinical example number two, new patient presents with complaints of diarrhea and left lower quadrant abdominal cramping. We'll schedule the patient for an outpatient lower endoscopy to be done at the hospital. Differentials include microscopic colitis, IBD. Patient is at a higher risk for this procedure due to his underlying conditions of CHF, CKD, AFib, and chronic anticoagulation. 99204. So you've got an undiagnosed problem, also minor procedure with identified patient risk factors. And that's it. All you need to do is just put that in your plan of care. It's just another sentence to add that takes your level from a three to a four. And it's very clear. This patient is high risk and this is why. All right, example number three. We've got an established patient who has recently been diagnosed with pancreatic cancer. The patient has significant pain, weight loss, jaundice, and fatigue symptoms. Recent imaging showed a significant stricture of the bile ducts. At this point, we recommend the patient undergo an emergent ERCP for step placement into the stricture. This is considered a major procedure for the patient given his diagnosis of cancer, severe weight loss, and fatigue. Patient is also noted to be jaundice. Risks and benefits were discussed with the patient and his spouse. All questions were answered. Okay, so this is a level five follow-up patient by decision making. Not only are we dealing with a life-threatening condition that requires intervention now, we also have a major procedure, urgent procedure. Guys, major procedure, urgent procedure, it's not defined by whether it's a minor or major surgery or procedure. It's defined by the urgent necessity of it. So making sure that you document this is not something, this is not a procedure that can be scheduled out in two weeks or three weeks or whatever. This needs to be done immediately. And that's what needs to be documented. Just making it very clear. The clearer that you can make it about the patient has severe symptoms, or this is a major procedure and this is why, risk factors, things like that, the more, I kind of call, you know, lay terminology you can use, the better off you are to support those higher level visits. And guys, payers are routinely looking at records, especially those high level visits. Some payers are even just reviewing them and just paying you the, you know, paying a difference and saying, yep, well, you billed a four, but we think it's a three. So we're just going to go ahead and just pay you the difference of that money. And if you are not looking at, you know, your payments closely, this could be something that you, you know, money left off on the table. I would appeal, you know, go, go up the chain. You at the end of the day can support that level that you're billing, especially if that assessment and plan is very clear. So again, 99215, it's very hard to get a high level visit out of the office by decision-making now. It's a lot harder than it used to be. Let's just say that. So this would be a good example of that. There's also one comment that I want to make and it's in regards to that patient or procedure risk factors. So there could be procedure risks involved as well. And I'm not talking about the statement that you have on every clinic visit that says risks and benefits were discussed with the patient. We know that's routine. That's part of the procedure that you're going to order. We're talking, maybe the patient has severe ulcerative colitis. They are a higher risk for perforation. Okay. The patient that had a food bolus and can't swallow, they have a higher risk for choking. All right. So that's what we're talking about with procedure risk factors. So it may be a patient that doesn't have comorbidity type risk factors, health risk factors, but given the scenario of the condition that you're treating, the procedure itself can be risky for this patient and this is why. So very important to also think about procedure risk factors as well when you're documenting. All right. Now we are going to look at some clinical examples by time. So again, I kind of mentioned this earlier is you get to select your level by decision-making or time. And one of the major changes that they had made with time-driven documentation in the office is it's not face-to-face time anymore. It's total time of the patient encounter. All right. So that, a lot of that time could add up. And if you think about it, this could be reviewing their history, reviewing records, examining the patient, counseling, ordering tests, charting, documenting your note counts towards time. So a lot of those elements, again, if you think about it can add up, especially on a patient that, again, they might be coming in for a follow-up visit, they're relatively doing well, they're low complexity by decision-making, but again, you can't get out of the room or they walked in with a stack full of records for you to look at, or they walked, you know, you walk into the room and it's dad, brother, sister, dog is sitting in there and is like, okay, this is probably going to be something that I need to time. Okay. So think about those scenarios. So here's an example of one. Chief complaint, patient is here for follow-up of her recent pancolitis flare. So she had a flare of her UC. She was vacationing with her children when she started to experience severe abdominal cramping and diarrhea and bleeding. She presented to an outside hospital due to the severity of those symptoms. Since being treated at the hospital, her symptoms have improved and back to baseline. No changes since last updated on history. Review of system, she has occasional episodes of abdominal cramping and diarrhea, but this is her baseline. No other symptoms were reported. Examination appears well, pleasant, no acute distress, normal GI examination. So impression, patient presented for follow-up after a recent hospitalization for her pancolitis flare. She had, again, developed significant pain, diarrhea, blood in the stool. Her symptoms have greatly improved since hospitalization, but due to the flare, I recommended her biologic infusions be shortened down to six weeks from the current eight. This was discussed with the patient in detail, 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. All right, here's the key. I spent 15 minutes reviewing her records, 20 in history and exam, and 10 documenting and adding those new orders for her infusion. Okay, adding up 15, 20, 10, 45 minutes, this is a level five by time. All right, not every one of your follow-up patients are going to be a level five by time. You know, that causes red flags and there's only so much time in the day. But this is definitely a scenario where by decision-making, she was stable. This is more of a level three. All right, but again, 99215. Could be a four because she's really, you know, chronic condition, not at goal situation. But anyway, you're getting a higher level because you're billing by time. There's nothing out there that says you have to have a start and stop time or you have to have all of this broken down. But I will stress, you have to have at least total time spent and details, details, details, details. You cannot just put your standard note and at the bottom say 40 minutes spent. You have to elaborate on what you did to support that time-driven visit. Number two, so here's actually an interesting one. This is a new patient. And where we don't typically bill by time on new patients, this one's a unique scenario and it kind of segues into a question we get sometimes. So this is a 53-year-old male, presents for transplant evaluation. So he needs his renal transplant, but he has to be, he has to have a colonoscopy. Colonoscopy has been done in the past, but it's been too long since his last one for that transplant evaluation. So plan, colonoscopy, prep education provided to the patient, and the procedure will be scheduled. Risks and benefits were also discussed with the patient. I spent 45 minutes in the total time of the patient encounter. Approximately 30 minutes was spent with the patient. Communication was very difficult as he does not speak English. Communicated via a translator over the phone. The remaining 15 minutes was spent in reviewing the patient's history and documentation for this encounter. All right, so if you look to a 45-minute visit on a new patient, that is a level four. This is nowhere near a level four by decision making. The patient really doesn't have anything wrong with them. There is no complexity of problems. There is no data. So this definitely would be a time-driven visit. And so the translator thing, we sometimes will get a question throughout the year that says, how do we bill for translator services? You can't. You have to, it's by law, you have to provide the patient with the translator. But if it prolongs your visit with the patient and the communication with your patient, you can incorporate that into more of a time-driven service, which could increase that level, which could, again, maybe you could kind of see a little bit of that reimbursement for that translator, but no, you can't bill for translator services separate. All right, and that is the end of my presentation for the case studies. And I think this actually takes us to the Q&A session. And it looks like, I think it looks like there's some questions that popped up.

E&M documentation

decision-making

time-based billing

clinical case examples

service code levels

risk factors

prescription management