Thank you, Dr. Sun, and welcome, everybody. And as we go through the first presentation today, we're going to be talking about the 2025 preview and current issues impacting GI practices. And while we go through this, I think you're going to see that I'm just going to kind of lay out the agenda, and I'm going to do an overview, but it will be followed up in more depth by all of the speakers this morning and this afternoon. So let's go ahead and talk about, we've got the first polling question, so we've got to keep you up on your, get your attention to this. And just a question. Good morning. Are you ready to go? And I know some of you are listening on all parts of the U.S. What did you have for breakfast this morning? Did you have coffee, an espresso, juice? Did you have a snack, a granola? Did you have a full breakfast? Some of you might be in bed. So Dr. Luttenberg's way out on the West Coast, and he's definitely got his coffee ready. So if you guys want to fill your questionnaire, that'd be great. Looks like they're waking up, Kathy. Okay. Last call for answers, and I will share the poll. Here are your results. All right. 64%. All right. 22% are in bed. Good for you. Okay. And none of the options, somebody said. Yogurt. Okay. Somebody's more healthy. Well, definitely. Okay. The next question that we've got is, we want to know how many members of your team are participating in today's course. Is just one of you, two to three, four to six, or seven or more? And they are responding more quickly, so it looks like they're up. Okay. I will go ahead and share the results. Here you are. All right. Great. Well, welcome, everyone. And as we go through, you do have the option to ask questions, Q&A. We also have a formal Q&A session after each one of the sessions is outlined in your agenda. So we'll keep on going. All right. So what I'm going to be talking about are changes to the 2025 ASC fee schedule, the physician fee schedule, screening colonoscopy update. Not too much this year, but just still some. We'll talk about the 2025 CPT codes, the 2025 ICD-10 update. I'm just going to do a little overview on that. Kristen's going to go into more detail on the specific changes. We'll talk about state legislation update and also talk about G2211. That went into effect last year, and just want to make sure that you all understand the nuances for specialty providers with G2211. So the first of the ASC fee schedule. Both the physician and ASC fee schedule were released on November 1st. But on the ASC side, and we're going to get an increase, but there are some strings attached to this. And they're using the hospital market basket update. We're looking at an increase of 2.9%. But, but, but, for only those of the practices that have submitted quality measures, all right? And if you did not submit your quality measures, you will not get that increase amount, and plus you may actually get an additional penalty. And I know a lot of practices are not necessarily aware of how to submit to the ASC. As far as that goes, the ASC is no longer just a claim submission where you use your G codes, G8907, et cetera, on your claims. It actually has to go through QualityNet. So this is an electronic submission of your quality measures. So just make sure we had some questions last year where some of the practices says, oh my gosh, I'm not even getting the full amount for my ASC approved rates. What's going on? It's because in the start of last year, it's because the, you did not submit your quality measures. All right, so just make sure that all of your, let's put it this way, your practice administrators, your billing directors, et cetera, know and have been monitoring this as well. So the final rule to the physician fee schedule, and Dr. Sung is going to go into more detail on this, but I think some of you probably are not very happy about it, and we are going to get a decrease to $32.35, again, pending what Congress can do. There was a bill introduced to the House on October 29th to block the reduction as well as to give an increase to the Medicare fee schedule. We'll have to see what happens with that. And I think as you have known in the past few years, this has been a common, this has been an every year occurrence where we've got this drastic reduction to the fee schedule and then we don't. But we still get a fee schedule reduction, but not as what they have published. And it took until March 9th of this year to get the 2024 conversion factor adjusted. All right, so currently we're getting paid at $33.29 per relative value in it. So, again, Dr. Sung will go over the proposed reduction in more detail. They're also talking about expanding colorectal cancer screening, and what they're doing with this is they're removing the coverage of barium as a method of screening. And I have a feeling not many of you have ever ordered this. A lot of times if you are not successful with the screening colonoscopy, you will go to a CT colonography. But as a result, based upon usage of those codes, that has not happened. They're also finalizing adding either a positive Medicare-covered blood-based biomarker test or a noninvasive stool test as part of the continuum of screening. And then that follow-on colonoscopy would not incur beneficiary cost sharing. So, again, the biggest thing is now they're going to cover a blood-based biomarker test. And as of yet, they have not officially released those that are covered. All right, there will be more information given to us probably mid-December. Back to the fee schedule. Back to the actual fee schedule itself. It was released on November 1st, but the Federal Register will not publish this officially until December 9th. So there are certain things within this that may not go through, but I think they pretty well will, except most likely is the final conversion factor. Telehealth services. All right, they're going to continue the telehealth services through December 1st, December 31st of 2025. And they are finalizing that they will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. There's another thing I did not put in this slide that is part of the Federal Register publication that will come out on December 9th. They're proposing to go back to pre-pandemic guidelines where only those patients that live in rural areas, health provider shortage areas as well, and some of those are also considered into the urban areas as well, to permit telehealth actually payments. So this is something that you all should be aware of, that in hopefully you're not doing near as much telehealth as you were several years ago, and even earlier this year. But what they're saying is just because it might be more convenient for the patients as well as the providers doesn't mean that it's going to be covered effective January 1st. Again, we do not have official guidance on this one, but I think you probably should reduce giving your patients that option of telehealth and encourage them to come back into the office setting. All right, the new CPT codes actually involve telehealth, telemedicine codes. And what they have added, and CPT has added, codes that actually duplicate 99202 to 99215, and there's 16 codes. Well, CMS pretty well said, nope, they're not going to honor these new codes. We're going to still use the codes that we have been using for years. Now, the 99202 to 215 with the 95 modifier indicating it's a telehealth service. Now, as far as the commercial side goes, we have no idea what they're going to do, if they're going to follow CMS on this, and a lot of times they do, or if they're going to utilize the new CPT policies and CPT codes. And those will be in the next few slides. So I would not get too overly excited about giving these to your providers. Obviously, they're not effective until January 1st as well. All right, so these are the codes. I'm not going to spend a lot of time on them, but you can see what the definition is. Synchronous audio-video visit with straightforward decision-making. And if using time, it would be 15 minutes or more. So that's the definition, and then underneath that is the established patient. And again, they're following the same time requirements. Now, this is audio-only visits. These are probably the codes that kind of make you question, well, how are we going to build this? If Medicare is not allowing for this, the audio-only visits, and it says it has to have 10 minutes or more of medical discussion, and if using time, it's 15 minutes or more. All right, so these are new codes for just audio-only visits because what they're doing is they're deleting our current telephone codes of 99441 to 99443. So we do not have any specific guidance yet for Medicare. Since they're not following the new CPT codes, what are we going to do with telephone? All right, we also have three new Category 3 codes that have to deal with esophagoscopy. All right, and it's specific to mechanical dilation with a drug-coated balloon catheter for an esophageal stricture, which, of course, includes fluoro. And then 0885T is for colonic stricture. All right, and so just those are three Category Ts. If any of you listening in are doing these procedures or having providers that are doing these new codes, this is for the ASC side. The hospital side can use these codes. On the physician side, we are pretty well stuck with an unlisted procedure code, and if this is truly a stenting procedure, we can usually just use the stent code for the physician side. And don't forget about using the common field. If you don't feel comfortable utilizing the stent placement codes and you want to bill it as an unlisted procedure code based upon the anatomic location, then you would have to end up putting in your comments in Box 19. And I'm going to give you more guidance when we go through the advanced procedure codes, which are usually unlisted. Making sure to use your comment field and put the name of the procedure, just the abbreviated is fine. Otherwise, the claim will not go through. All right, next are the ICD-10 codes, and these are, I'm not going to go through each one of these because Kristen will give you more detail on this, but you can see some changes to the obesity codes, fistula codes. I will cover these last few codes, and I think this is a common question we're going to get today, and I know some of you listening in, and as we go through today, we may have more people that have registered but have not just jumped on just yet. Personal history of colon polyp codes. All right. Providers, very important for you to make sure and document what type of polyps the patient's had, if you know them. And we have specific adenomyosaroid polyps, and they give us a description of what that includes, hyperplastic, and other colon polyps. All right, so we do have an issue with this right now. Since October 1st, Medicare and Medicare replacement plans have been denying these claims submitted with the revised personal history of polyp codes. And this is associated with your code of G0105, which we submit for any type of high-risk screening, and Medicare continues high-risk screening as personal history of polyps, personal history of cancer. All right. But the claims have come back since October 1st with a denial reason that says lacks medical necessity. It can be an invalid code. We've seen a whole bunch of different denial reasons. This is probably our most common question that we've had on the hotline since probably mid-October. Appeals are ineffective. Calls to multiple MACs as well as CMS have returned information that the implementation date is now 11-26-24. And so when we're talking about this, we're talking about thousands of claims that pretty well translate to millions of dollars that are just kind of left there. Appeals right now are ineffective. So for those of you that have this question in the back of your mind, you're not doing anything wrong. This is a glitch in CMS, all right, that they will potentially resolve, and hopefully they'll reprocess the claims. But right now they're saying they're not. All right. We've gotten information from different practices, talking to Neridian, Novitas, First Coast, WPS, CGS, NGS. They're all getting the same thing, that they're saying, well, it's not covered. It's not an approved ICD-10 code. The National Coverage Determination was published, and it is effective, and it does contain all of those new codes. So again, this is a glitch within CMS. This is the transmittal that you can get into, and there is a link on the bottom of this slide for more information. But you can see that the 10th revision, it says it's effective April of 2025, and the implementation date is 11-26-24. Why they would make any changes with the new codes not until April of 2025 is beyond me. All right. Of course, that's my opinion. But remember that all of our ICD-10 changes became effective on October 1st. Last year, we had this same issue with family history of polyp codes, too. And a lot of the payers did not even start recognizing those codes until November 1st. But the commercial payers aren't the problem here. This is Medicare, right? Medicare and Medicare Advantage plans. All right. Now, I know some of you listening will say, okay, it's not just Illinois that's working on this. But on August 9th of 2024, Governor Pritzker signed a House bill which requires insurance companies for coverage for all colonoscopies in patients that show signs or symptoms of colon cancer or have an existing colon condition. This grants free access to all colonoscopies deemed medically necessary in the state. All right. So this has gone into effect. So any of you practicing in Illinois or the border states to Illinois, just to be aware that your patients residing in Illinois will be allowed preventive care coverage on personal history issues, which is big. this is great. And we do know that there are several other states that are currently have existing legislation as well. So good news, hopefully down the line, all states will allow for this and we'll definitely reduce the patient's complaints, which we understand them. But that's one of the things that we have to field on a regular basis in the practice. Patients call in and said, well, insurance company said, if you quoted it this way, it would have been covered. And hopefully there would be no problems once all states have adopted similar policy, but it's gonna, it's a long, it's been a long road to get some of this legislation through. Let's talk about G2211. All right, so since January 1st of 2024, CMS finalized implementation of a new E&M office visit, which is code, it's an add-on code to 99202 to 215 codes. And what this does, it enables practitioners to build longitudinal relationships. And I don't know how many times I have used the term longitudinal, I can't count it. With all patients, not only those patients who have a chronic condition or single high-risk disease. And it extends across multiple sites and for the duration of an episode of care. It is not just for primary care providers. It is also for specialty providers as well. So if you are taking care of a chronic condition or a single high-risk disease and your documentation supports it, and this is the full description, and I will read this slide through. It's a visit complexity inherent to E&M evaluation associated with medical care services and that serve as the continuing focal point for all needed healthcare services and or with medical care services that are part of an ongoing care related to a patient's single serious or complex condition. Now we're talking around $16 additional. But considering that is how many patients that you are managing with chronic conditions such as IBD and liver, et cetera, this does add an additional amount of revenue. When this was released, this was a Medicare only code, but we have seen some of the commercial payers also pay for this as well. Make sure that you know who does and who doesn't before you decide to submit G20 to 11. Well, we're gonna just submit it to everybody. I can tell you right now, Medicaid will not cover it, but in UnitedHealthcares, put a stop date on that, September 1st of 2024. Just know your payer policies, keep a spreadsheet. We'll probably be telling you this as we go through the day, especially Kristen and I. You need to monitor payer policies. You have to keep information on there so that you can share this with all of your coders, your billers, all your providers, anybody even with pre-authorization. And we're not just talking about G20 to 11 on here. It is so important that this is communication between everybody involved in the patient's claim process. It's so important. So this should be used by medical professionals regardless of specialty with E&M visits of any level of care. So it's reported with the codes, like I said before, 202 to 215. Now, it is not payable when you're using modifier 25 on that visit. So you might be utilizing, say 99214 with a 25 modifier on the same day somebody's coming in for an infusion. All right, and this visit is unrelated to the infusion service. Well, would you rather get paid for that visit? I should say that infusion, or G20 to 11? You definitely would rather get paid for that infusion service. So make sure that any time that you do any type of service that day, this could also be hemorrhoid banding. This could also be any type of liver elastography service that day, et cetera. Remember that any time that a visit is used with modifier 25, the G20 to 11 does not get assigned. And hopefully you have that set up in your parameters in your billing software. You can actually make sure that whoever's entering the charges knows that G20 to 11 does not get submitted when you are billing a visit with 25. For more information about G20 to 11, there is a link that you can utilize. So this is kind of what they have given us an example for, for CMS. They actually use neurosurgery, and I kind of converted it over to GI. So the patient admits they've missed several doses of medications and symptoms have increased. And what they're saying, and I understand what they're saying on this, but it's kind of, when you read through it, it's like, wow, really? That guests or neurologists must weigh his or her response during the visit, the intonation of their voice, the choice of words, to not only clearly communicate the importance to not miss doses of IBD medicine, but also to create a sense of safety so the patient feels comfortable in sharing information on non, let's put it this way, on noncompliance with the treatment plan. All right, so because the gastroenterologist is part of ongoing care must weigh these types of factors, then this visit becomes more complex and the practitioner bills the code of G20 to 11. And even though you might not be the focal point for all services, Crohn's disease is a single serious condition, and we know that. And as long as you plan on doing continuing care with this patient, then the visit is billed with an add-on code. And this is not just one visit. You're not limited to a max of one visit per year. You can use this any time that you're coming in and continuing care with this patient. But guys, the documentation in the assessment and plan has to be there to show that you have a continuing relationship. You are planning on, let's say for Crohn's in particular, you're doing quarterly labs on this patient that's undergoing treatment with biologics. All right, you're saying when the patient should come back, you are talking about potentially immune issues. You know, all of that information, it's so important that you document that. And you don't have to write a novel in your assessment and plan. All right, so. If you have a single series complex condition, and again, I talked about this before, IBD, chronic liver disease, could be celiac, an add-on code can be built. But again, it is completely dependent upon the documentation by your providers. All right, so, and these are some examples where the G2211 would not be reported. I don't think you're doing any mole removals. Treatment of a virus, seasonal air allergies, its initial onset of gastroesophageal reflux disease. Most of the time, that's not you. You're seeing the patient that does not respond to the, let's put it this way, the normal treatment, all right? You're seeing the patient because they have not had success or they've had breakthrough symptoms, et cetera, right? If you're continuing management of that continue, that complex disease, then yeah, you can utilize that, right? Comorbidities are either not present or not addressed when the billing practitioner has not taken responsibility for ongoing medical care for the patient with consistency and continuity over time. And we've had quite a few questions on this. Well, then that means that we can never bill this on a new patient visit. No, that doesn't mean that. It means that if this patient is being transferred to your care to manage that condition and you are going to manage that condition and that's documented in your suspended plan, you can bill G2211 with the new patient codes. But if the patient is coming into your practice and they have signed in symptoms and you're in the process of doing a workup where you do not know whether or not you are going to continue management of this patient for a long period of time, that is probably the one that you're not going to be able to bill G2211 with. So here are some references from your different payers on the G2211. Some of the payers give you way more information than others with some examples, but most of them do not have examples. So here is just some of the, this is just a copy of a visit that we have looked at that would support the G2211. So 34-year-old with chronic alcohol abuse findings in April of 2023, most recent imaging with no concern for hepatoma, but findings of cirrhosis and portal hypertension, needs continued hepatoma screening and EGD to a screen for varices. So this is alcohol cirrhosis of the liver, continue abstinence, CMP, reschedule EGD, return visit in six months and ultrasound in January. This is what you need to support G2211. You have a continued care plan and you are going to have, you're providing longitudinal care for the cirrhosis. All right, so here's another one. Not supported by documentation. Who comes in the office with chronic loose stools, no clear etiology, stop imodium, fecal elastase, follow-up PRN. Even though this is a chronic problem, there is no longitudinal care involved. Just the follow-up PRN, not enough. What other information may you have given this patient that you did not document? All right, so again, it is all up to the providers to document, again, longitudinal care. What is your care plan for this patient? Some of you are very good at this. Some of you are very verbose. And when I say verbose, I mean that you are specific. All right, you can see it. You do not have, like I said, you do not have to write a novel. Just on the previous slide, it doesn't take a lot to document and support longitudinal care. All right, so again, totally up to the providers to document, and some of you may be better than others. And some of your electronic medical record systems can help you with this, and some of you cannot. I'm gonna tell you right now, do not use a templated statement that said, I provided longitudinal care. And we've seen this, and we've been asked before, will this statement hold up? Is this something good that we can use? No, that's not good enough. You have to specify. It's just like when you're talking about time elements on your E&M services, you can't just say, I spent 40 minutes, and that's it. Nope, you have to elaborate. You have to support why this is. All right, so again, completely and totally up to the documentation by your providers. All right, so we've got way more to talk about today. And I know I've seen some questions up, and we'll get to those in just a little bit. So we've got, we're gonna talk about ICD-10 and HCC risk adjustment. We're gonna look at an overview on all E&M codes, decision-making guidelines, the all-familiar topic of screening versus diagnostic colonoscopy, medical necessity issues, pathology ancillary services, anesthesia services, the top issues impacting GI practices. And again, so much more because a lot of it's going to also be triggered by your questions. All right, so guys, thank you so much. And we're gonna go into overview of E&M documentation with Dr. Sun. Take it away. Yeah, thanks so much. We actually are doing very well on time. I'd like to take a few minutes to address some of the questions and ask you to answer some of the questions that have come up during your session. First of all, for the audience, if it felt like a lot, it is, but we're gonna go through everything in detail. Kathy, can you speak more about submitting quality measures to ASCs and how this might have been affected by the outpatient payment update? Quality measures. All right, so it's qualitynet.org is, and I would probably recommend that you just go to that website. There's so much information in there. It tells you exact, it gives you all of the detail to the quality measures and what you need to submit. And it's a very simple process. You just need to get a username and password to get into the system. And this is not new. We've been utilizing this website even before COVID. But it wasn't mandatory for submission. We had a pause during COVID to submit quality measures, but it ramped up again in 2023. And it really did not become mandatory until 2024. And we're seeing the effects of it now. Another respondent had written, regarding telemedicine, did incident two billing change? Can a provider be available by a phone or video and not physically in the office for supervision? What are current rules regarding incident two billing and supervision by the collaborating physician? Kristen, I know you're on. Do you want to kind of touch on that a little bit? Yes. So right now there still is some, and this is all payer specific. I hate to say that. There's not really a one-way street here. Since they've lifted the public health emergency, payers can do what they want. Some don't even follow incident two. And I'm going to discuss that more when I get into my talk on shared visits and split shared policy as well. So I'm going to get into a little bit more detail on that. And I will elaborate on the telehealth and the direct supervision, what needs to be documented, things like that. But again, right now there are certain things that can be overseen virtually, but again, you're back to payer specific policy. Great. Regarding Z86.010X codes, we're getting denials from UHCMCR. Should we just bill Z86.010? And absolutely not. All right, that code is gone. And if you bill a Z86.010, you're going to get a denial for a truncated code. All right. So right now this is CMS and the Medicaid Advantage plans have said there's a glitch. And so what you can do with this, I mean, we're so close right now to 1126, where they're going to, let's put this way, implement those codes at that point in time. I would hold off on any denials, appeals at this point. We've had questions as well. Should we just hold off on our claim submission as well? That's completely up to you. I mean, when you at least submit a claim, you're going to get documentation from electronic claims remittance that shows that the claim was submitted and filed in a timely fashion. But like I said, we're so close right now to, it's 10 days away. Do you want to just hold it and submit it at that point? I don't have a good, I wish I had a magic wand for this. And I wish, I would hope that CMS will come back with some type of transmittal. And I have a feeling they will. After that point, that says they'll go ahead and reprocess these claims. And I have a feeling they will. But like right now, I don't know. So do not build with Z86.010 because that's a compliance issue. You are using an outdated truncated code. Thank you for that, Kathy. We did get a couple of questions about G2211. I answered one of them in the chat that remember G2211 is an add-on code. So you would build both for the visit. So for example, 99214 and put G2211 on top of that. Another audience member asks, do we have a list of chronic GI conditions that are covered? I think what's more important is that you establish in your assessment and plan that you are responsible for the longitudinal care of this single serious condition. For example, Crohn's, ulcerative colitis, fatty liver disease, cirrhosis, and even GERD. If you're the one managing the patient through multiple different PPIs, then that can count as a single chronic condition that you're primarily responsible for. And you can build G2211. Just a point of housekeeping, these slides are all gonna be available on GILeap. And we'll do our best to answer the questions in real time. But what we're also planning on doing is we'll answer questions during the Q&A session, as well as preparing a document for the audience after the conference is over. And that'll be posted on GILeap as well that summarizes themes that come up from your questions. And we'll do our best to answer them. Thank you.

gastrointestinal practice

fee schedules

telehealth services

ICD-10 updates

G2211 code

state legislation

colorectal screenings