So, in this session, I'll provide an overview of the evaluation and management documentation guidelines. For many of you, this is a review, but I'll be sure to point out nuances that can make tangible differences in your practice's bottom lines. Whether you're a coder, biller, practice manager, or clinician, this really is the beginning. It all starts with our documentation, and knowing the rules is critical to helping providers get the credit they deserve and to setting practices up for success. I have no financial disclosures. I'll be discussing trends that Kathy had mentioned regarding the physician fee schedule as the why this is so important. I'll discuss E&M visit rules, billing by medical decision-making, including a discussion of social determinants of health, ICD-10 codes, and billing by type. So, despite increases to the Consumer Price Index to payments to skilled nursing facilities and hospitals, Medicare physician payments have not kept up with inflation. The MEI, or Medical Economic Index, is an annual measurement of inflation based on a number of factors, including salaries and wages, the housing component of the Consumer Price Index, non-physician employee compensation, and the cost of medical equipment and rent. It's a measure of physician practice operating costs. We've seen an increase over the years to the Consumer Price Index with concomitant increases in payments to skilled nursing facilities and hospitals. However, while the MEI of practice cost has grown exponentially over the past few years, physician payment has nowhere near kept up. In fact, adjusted for inflation and practice costs, Medicare physician payment had declined 29% from 2001 to 2024. CMS uses the Medicare Physician Fee Schedule, or MPFS, to reimburse physician services. As you probably know, total RVUs are based on work, practice expense, and liability, adjusted locally for a Geographic Practice Cost Index, or GPCI. Payment is your total RVUs times a conversion factor, and as Kathy had mentioned, on November 1st, CMS issued a final rule for the 2025 Physician Fee Schedule, which goes into effect January 1, 2025, and as Kathy mentioned, the 2025 conversion factor is $32.35, which is a decrease of 2.83% from 2024. Now I've plotted the conversion factor over the last five years, and this is the trend. Because of this conversion factor decrease, we're making less each year for the same amount of work, and some would argue for more. So remember, now more than ever, with decreasing reimbursements and increasing costs, costs of doing business in terms of labor, capital expenditures, there's a tremendous increase in pressure to produce, and that's why now more than ever, it's important for physicians to understand the basics of coding and billing to stay abreast of those changes to the rules in order to bill accurately and to receive full payment and to bill effectively to make more for the work that we do. And documentation is the key. It's the first step. Coders and billers can only work off what we document, so let's get into the details. So remember all the bean counting, the need to document 10 review systems and 8 physical exam areas? All of that went away. And I think CMS recognized the need to reduce administrative burden, and the Patients Over Paperwork Act of 2021 helped to reduce documentation requirements for outpatient E&M services. We saw similar coding and documentation changes for E&M visits in the hospital or inpatient setting that went into effect at the beginning of 2023. These changes included revised guidelines for medical decision-making, or MDM, and the elimination of history and physical exam in determining coding levels. So a history and physical exam are still required, but we should only include what's pertinent, what's relevant to the chief complaint. You can also document that there were no changes to the patient's family, social, or surgical history since the last update in the chart. You'll no longer have to include documentation about the patient's family history, that their lungs were cleared, or auscultation bilaterally, unless it's relevant or pertinent to the chief complaint. We still have to include a chief complaint, the specific reason we're seeing the patient, and Kathy and Kristen can attest to bills not being paid because the chief complaint was listed as sent by PCP. That's not good enough. So I do want to stress the importance of documenting only what helps in your medical decision-making or what's clinically relevant or appropriate. A group from quality and medical leadership at my institution conducted a six-month review of all 21 hospitals in my health system. They found 2,743 discharges with malnutrition as a contributor to the major complication or comorbidity, or MCC, for that discharge's MS-DRG. They reviewed 50 cases in detail and found the buttons for well-nourished and well-developed in the EMR clicked, so it was documented as so, in 27% and 37.5% of those 50 cases respectively. The total number of dollars at risk from documenting well-nourished, well-developed, while coding for malnutrition because there's a conflict there totaled $278,454, with a per case at-risk dollar amount of $5,500. So for all 21 hospitals and 2,743 discharges coded with malnutrition as a contributor for the MCC, that's a combined annual at-risk dollar amount of $17,500. Suffice it to say after this investigation, health system-wide education went out about only documenting accurately and only what's clinically relevant. So what in our documentation determines the level of billing? Now it comes down to two pathways, billing by medical decision-making or billing by time. So using medical decision-making to determine the level of billing consists of three components. I call this PDR, problems, data, and risk. The number and complexity of problems addressed, the amount and or complexity of data reviewed and analyzed, and the risk of complications, which include morbidity and mortality from your plan or patient management. The best advice I can give you is to focus on your plan of care, what you addressed and what risk factors impacted how you care for the patient. These are the levels for each element in MDM. The rule is you need two out of three elements for that level MDM that must be met or exceeded to determine your level of billing. So two out of the three columns must match or at least be exceeded. So for example, if you have moderate number of complexity of problems, a moderate amount of data that you've reviewed, but only a low risk of complications and morbidity or mortality for the patient in the management of the patient, you can still bill a moderate because you have moderate problems, moderate data. So these, what I have here are codes listed for office outpatient initial visits, subsequent visits, and then the initial hospital inpatient and subsequent hospital inpatient codes. In 2023, note that 99201 was deleted and as specialists for that matter, we should never be billing level one or even level two outpatient codes. Our office or outpatient follow-up visit codes 99212 to 215 are listed here and our subsequent hospital outpatient or observation codes 99231 to 99233 are listed here. Now for those GI practices with inpatient services, you actually have a service that you admit to and you follow that patient every day on that service. Remember, there are no longer specific codes for observation services. Ops codes 99218 to 99220 and subsequent observation care code 99224 were removed from the code set. Inpatient codes 99221 to 223 and 99231 to 233 were revised. So the code descriptors actually say inpatient and ops or observation. From a provider standpoint, we would see the patient, document our finding and recommendations and then submit the appropriate code based on our level of billing. What determines whether the bill gets sent out as ops or inpatient depends on the place of service. So place of service 21 for inpatient admissions or place of service 22 for ops. The patients need to meet certain criteria for inpatient admission, otherwise the bill is backed down to ops or treat and release. And there are rules regarding ops, including a MOON or Medicare outpatient observation notice, which details the implications of the outpatient status such as co-pays. But that's beyond the scope of today's course. Just know that billing should determine and reassign the place of place of service based on our documentation as providers and the need for inpatient hospitalization. So here's the official grid with all the rules determining medical decision making. In the next few slides, I've broken it down to a very simple guide that combines both outpatient and inpatient roles. So let's look at the number and complexity of problems addressed first. Remember that problems need to be addressed in our assessment and plans. Auditors are not going to look in our history of present illness or HPI to see if we've addressed problems there. Second, address specific problems that the patient is seeing you for. They may be coming in with diabetes, AFib, CAD, but you're not touching any of those problems. They shouldn't be in your plan. There are three levels of problems addressed, low, moderate, and high. So let's look at the rules. For low, you just need two or more self-limited or minor problems. You need one stable chronic illness or one acute uncomplicated illness or injury, one stable acute illness, or one acute uncomplicated illness or injury requiring hospital inpatient care or observation level of care. So this really could be reflux, patients doing well, they need a follow-up appointment but no prescriptions were written. A patient who's not at his or her treatment goal is not stable, even if the condition hasn't changed and there's no short-term threat to life or bodily function. So anyone who's not at their treatment goal is automatically moderate. So for moderate, you just need one or more chronic illnesses with exacerbation, progression, or side effects of treatment, or two or more stable chronic illnesses. This could be Crohn's or ulcerative colitis with mild flare or someone who's coming in with both reflux and IBS. You need one undiagnosed new problem with uncertain prognosis or one acute illness with systemic symptoms. So if a patient comes to you with acute symptomatic anemia to see you in the office, that automatically counts as moderate complexity. It's an undiagnosed new problem with uncertain prognosis or it's an acute illness with systemic symptoms if they're having shortness of breath or some chest pain along with the anemia. So when it comes to high, now if you're seeing a patient in the office with one acute or chronic illness or injury that poses a threat to life or bodily function, and you're either doing something immediately or sending that patient to the emergency room, that counts as high. If you have one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, so if you're seeing a patient with cirrhosis with new onset of ascites or a patient with ulcerative colitis now with significant increase in bloody bowel movements, that would count as high complexity. Let's move on to data. So in terms of data and review of analysis, limited, you must meet the requirements for at least one of these two categories. For moderate, you have to meet the requirements for one out of these three categories. For high, you must meet the requirements for at least two out of these three categories. The move from limited to moderate is actually really just these two categories merged into the first category for moderate. So let's look at limited. Category one, you're reviewing tests and documents, and it needs to be any combination of the two of the following. Review of prior external notes from each unique source, review the results for each unique test, or ordering each unique test. And then category two is assessment requiring an independent historian. So this could be a patient coming in to see you who's got Parkinson's disease, they have Alzheimer's, and the additional history that you're obtaining is actually from someone accompanying the patient. Document that. Actually put, additional history was obtained by so-and-so because of the patient's XYZ condition. That will give you credit. If you look at moderate, it's just these two categories, in category one and category two for Limited merged into Category 1 Intermoderate. Instead of two of the following, it's just any combination of three of the following. Review of prior external notes, review of results for each unique test, ordering each unique test, or the assessment requiring an independent historian. So what counts as tests? Tests are imaging, labs, physiologic data. Consulting another service for their input is a decision and also counts as well. Ordering a test, reviewing an external note, and obtaining history from a patient's family member would satisfy Category 1 requirements for moderate complexity. Independent historian we've spoken about. And then a CPMP and a liver panel, believe it or not, count as two unique tests. So when you order a test, be specific about what you're ordering and why. Make it clear to the coder and the auditor, for that matter, how the test is helping you to make your decision. Let's talk about Category 2 under Moderate and High. If you review endoscopy images and form your own impression that helps inform or guide your decision making, that counts as an independent interpretation of a test performed by another physician. So independent interpretation of a test performed by another physician, that could be a CT scan, and you're writing, I personally reviewed the CT images from X and Y date. This is what I see. Sometimes we'll have patients coming in on the inpatient service with unexplained fevers. And then when we look at the CAT scan, we see that they're FOS, right? They're full of stool. And the radiologist typically doesn't comment on that in their report. So if you put that into your assessment and plan, that counts as an independent interpretation of a test. So just remember that where problems, you really want to document that in the assessment and plan. Data can be higher up in the note. And personally, I still put it in the assessment and plan and make it easier for the coder, and in case you're audited. The difference between Moderate and High, so the third category for Moderate is discussion of management or test interpretation. So if you've called an external physician or other qualified healthcare professional to discuss the case, if you've called the pathologist to discuss the results from your biopsy, so if you've called the cardiologist and discussed the anticoagulation being given a patient, that counts as Category 3. So just remember to achieve Moderate. You only need one out of these three categories. And for High, you only need two out of these three categories. And they're the same categories between Moderate and High. For most patients that we see, inpatient and outpatient, we're going to be satisfying Category 1, no problem. And for High, you just need either another independent interpretation of tests or a discussion or management of test interpretation with an external physician. All right, so risk. Risk of complications is relatively new and really has the greatest opportunity in the MDM table. What's key to know is that a patient with low probability of death may still be high risk. Documenting the risks that contribute to the need to forego additional testing, treatment, and or hospitalization all count to your level of risk in medical decision making. And if you don't specify otherwise, coders and auditors will assume that the procedure is low risk. Just remember that for this category, the American Medical Association states that it's up to the provider to determine the level of risk. So high risk for medication, the patient may be high risk for medication because of their chronic kidney disease. They may be high risk for a procedure due to their cardiac and pulmonary status. In your note, you want to document that the patient is at high risk for developing these conditions because of the following factors and then list them. So what's important is CMS does list some examples. Let's talk about prescription drug management. Remember, though, that these are only examples and that it's still up to the provider to determine the level of risk. When it comes to prescription drug management, the difference between over-the-counter and writing a prescription is important. In terms of prescription drug management, the golden rule is that if you're writing a prescription for the medication as opposed to over-the-counter, you're managing it and it counts as moderate risk. But be specific. Be sure to include the name, the dose, and the frequency in your assessment and plan, in your documentation. Our EMRs really should be pulling that through in our notes. And if it's not, that's an opportunity. What's the difference between minor surgery and major surgery? So you see here it says under moderate, decision regarding minor surgery with identified patient or procedure risk factors, decision regarding elective major surgery without identified patient or procedure risk factors. So in the eyes of CMS, diagnostic endoscopy is considered a minor surgery. According to CMS, a major surgical procedure is a procedure with a global period of 90 days. Minor surgical procedure has a global period of 0 to 10 days. That said, it's up to the provider, though, to determine the level of risk. So the difference between a major surgery with moderate and high is the presence of a patient or procedure risk factors. So an ERCP actually has a 90-day global period and would be considered a major surgery. If the patient has AFib and you're holding the anticoagulation for the procedure, that patient can be considered high risk and you should document it as such. We're going to go back in the next slide to talk about social determinants of health and ICD-10 codes. But let's talk about high. So if a drug therapy requires intensive monitoring for toxicity, if you're making a decision with regards to elective major surgery with identified patient or procedure risk factors, if you're making a decision regarding emergency major surgery, you're taking that patient, even if it's a minor procedure, but you're taking that patient for an emergency procedure, such as a patient for an endoscopy on the inpatient side with suspected bare seal bleeding, that counts as high risk. Even the decision regarding hospitalization or the decision not to resuscitate or to deescalate care because of poor prognosis or their poor comorbidities, that counts as high risk. So remember, if you're documenting that a patient is too high risk to get a procedure and your input contributed to that decision, you should get credit for that, and that counts as high. One thing to notice about all of this, it says decision regarding. So if you're seeing a patient in the office and you're writing that the patient is at high risk for endoscopic evaluation and you're therefore holding off on a procedure favoring conservative management, that counts as high risk. Don't think for a second that because you're not doing a procedure, you can't write down that the patient is high risk. Risk, again, it's up to the provider to determine the level of risk. All right. Let's go back now and actually talk about social determinants of health. We'll take a look at this in greater detail. So these codes for social determinants of health are important because they can count towards the risk element in medical decision making. Your patient says, I can't afford my medicine, I have stressors, I lost my job. All of these factors contribute to that risk. And they contribute to the patient's compliance with your treatment plan. So take a look. That's Z91.190, noncompliance with a low-sodium diet in a patient with decompensated cirrhosis counts towards risk. And that's Z91.110. I actually have a list of these on my wall, so when I'm doing my billing, I'm actually putting these in for patients where it's applicable. Payers are paying close attention to outcomes. Documenting these risk factors will help to explain why some of your patients have frequent hospitalizations or why they're not getting better. It's not because you're providing poor care. So you want to get the credit you deserve. What's really important here is don't just document the risk factors. Make sure your coders know to code for them, because if they don't, they're not aware of these new ICD-10 codes, then they won't code for them, and you won't get credit. And you want to get the credit you deserve. So the next two slides, so we've talked about medical decision making. Remember the rule that you need at least two of these categories fulfilled in order to determine that level of medical decision making. And these are the codes for your outpatient office visits, initial and subsequent, and then hospital inpatient or observation codes, initial or subsequent as well. All right. So these next two slides detail rules by billing or billing by time. And time is defined as the time spent on the day of a patient's visit or the day of the encounter. This includes both face-to-face time and non-face-to-face time. This is the time spent reviewing tests, performing the history, the exam, the time spent ordering medications, time spent coordinating care, even time spent writing your note or documenting. It's important to note that the time requirements for the highest levels of billing are set, they set very high bars. Spending 74 minutes caring for a patient in the office is spending a lot of time. So I do think the strategy for most of our visits can be supported by medical decision making. That said, we've all had those patients where you spend time contacting outside providers, where the patient's condition is stable, so they'd be low MDM. But you spent a lot of time discussing their condition with them, discussing the importance of diet and exercise, reinforcing the plan of care with them and their families. And those minutes can add up. So you'll be able to get to a 99215 level 5 follow-up visit if you document that you spent 20 minutes with a patient, 25 minutes reviewing their records, coordinating their care, and documenting the total time that you spent taking care of that patient. It's actually important to break down how the time was spent. Auditors are red flagging notes that just say a total of 45 minutes was spent taking care of the patient. So you want to be specific with how you're using that time. 99417 can be used for each additional 15 minutes of total time over 90 minutes spent caring for the patient, and it's worth 0.61 work RVUs. Now, you'll see here on the right that I've listed codes 99242 through 99245. These are consult codes, and I list them here because some payers still accept them. Many payers, Medicare in particular, don't accept consult codes, but some still do. For new providers, ask your billing department whether to use consult codes or the office or outpatient visit codes 202 through 205 or 212 through 215. That's highly institutional specific. For inpatients, again, I'd recommend seeing if medical decision-making will justify your level of billing, but if you spend a lot of time reviewing records, speaking with families, other providers, coordinating care, and it adds up to 50 minutes on the day of service, that would count as a level three high follow-up visit. For subsequent hospital inpatient visits more than 65 minutes, you can use 99418 for each additional 15 minutes that you've spent, and it's worth 0.81 work RVUs. Again, here I've listed the consult codes 99253 to 255 for those institutions that still honor them. Okay. Here as a summary slide, I've listed very common GI procedures as well as our CPT consults or outpatient visit and initial visit codes, subsequent codes as well. You'll see the work RVUs listed as well, and I do this to point out that a level four outpatient initial visit is worth more than an EGD with biopsies. When you look at a level three initial hospital consultation or visit, that's worth just as much as a colonoscopy with biopsy. So paying attention to these rules and how we document is so important because if you just move from a level three to a level four or a level four to a level five and do this for just four visits a day, three days a week for 48 weeks, that's an extra $23,000 per year. I don't know of any other practice improvement project or initiative that can get you an extra $23,000 just like that. And so for a four-person practice, that's an extra $100,000. For a 10-person practice, that's the salary of another nurse practitioner. And for the 200 attendees signed up for this course, assuming for a moment that you're all billing providers, that's $4.6 million. So the volume multiplier for small changes is real and can absolutely make a positive impact on your practice. These are some resources, and I will turn it over to Kristen Vaughn, who in the next session will take all of these rules and provide real-life examples that are very practical and helpful. Thank you.

E&M documentation

medical decision-making

ICD-10 codes

Medicare payments

administrative burden

revenue gains