presentation today on billing and coding. Jill is an adult nurse practitioner at Providence St. Joseph Health. She has practiced as an NP for over 15 years specializing in gastroenterology. Her practice includes evaluating and managing new patient GI consultations, follow-up visits, and diagnostic flexible sigmoidoscopies. She developed a passion for understanding the language of coding and became credentialed as a certified coder, a clinical documentation improvement specialist, and a risk adjustment coder. This led to developing the role of a provider liaison in Revenue Cycle, which included assisting with organizational implementation of ICD-10 and CPT-ICD-10 coding education for multi-specialist providers. She previously has served on the ASGE Reimbursement Committee. She received her doctorate of nursing practice from UC Irvine, master of science degree in nursing from California State University in Long Beach, and her bachelor's in nursing from Alfred University in New York. She has been published in Gastroenterology Nursing, the Journal for the American Academy for Nurse Practitioners, and the Journal for Nurse Practitioners. She is a new column editor for specializing in coding and billing topics for the Nurse Practitioner Journal. Jill is a past president of the California Association for Nurse Practitioners, past president for the American College of Nurse Practitioners, and past president of the American Association of Nurse Practitioners Scholarships and Grant Foundation. I certainly have learned a lot from her over the years in billing and coding. Jill, welcome. Thank you. Thank you, Sarah, and thank you for the committee inviting me back to speak again. This is my absolutely favorite program to talk to. Here are my disclosures. So I'd like to go through the first polling question. What is the most common follow-up office visit coded in the gastroenterology department? So the most common CPT coded in a gastroenterology department is 99214. Okay, next question, next polling question. What component of the note determines the level of the service? And when I use the term level of service, that means either your CPT codes, your 99213, 99214, 99215 for established visit or a new patient visit. Very good. This is great. So medical decision-making is the component that determines the level of service. And you'll see how perfectly Dr. Vicari's presentation works into this, because when you use the terminology, if you think it, then ink it, that's the medical decision-making. That shows that you're putting thought into the decision-making and coming up with a plan for your patient and describing the complexity. The complexity of the patient is going to drive then that numerical value of the CPT code that you're choosing. So my hopes this morning is to go over a review of the revenue cycle process. I want to give you some examples on how to differentiate ICD-10-CM codes versus CPT codes versus HCPCS codes. We're going to go over E&M, which stands for evaluation and management coding guidelines. We're going to review the definition of medical necessity and then also describe the importance of capturing accurate data so you can tell the story of your patient visit. So what is the rationale for coding specificity? Well, it's going to allow us to better represent and communicate that clinical scenario of our patient visits. What we're doing is we're translating an encounter, a human interaction face-to-face into numerical values that gets then transmitted to a billing department and then insurance company, and then they're going to assess whether that's the accurate code for reimbursement if there ever was an audit. So we want to start doing more precision data mining. We hear a lot about personalized medicine. How can we personalize medicine and or populations unless we start looking at data mining? And insurance companies have been ahead of us for a very long time in looking at mining that data. Also for CMS, the Centers of Medicare Services. There's a lot of data that they've been collecting and mining. One of those examples are when you look at Medicare Advantage patient population, the risk scores are based on the acuity of the ICD-10 code. And what CMS is finding is that we code better or programs or organizations for Medicare Advantage patients at a higher acuity than regular Medicare patients. So they start comparing these huge databases and populations. And so the values that they've given to previous codes for ill patient in the past, they readjust those and they start to reduce that weight or that reimbursement based on aggregates of other non-Medicare Advantage patient populations. So this gets into this accurate picture of looking at individuals versus attributed patients. ICD-10 diagnosis coding potential will enhance population health management because now you're using one numerical code value to describe very discrete instances for that patient. So someone who's diabetic, whether they're in control or not in control, whether they're on insulin and whether they have chronic kidney disease, and then you're even sub-specializing that into what type of kidney disease it is, whether it's 3A, 3B, or to end-stage renal disease. And it's looking at this more transparency between what we're coding versus our physician colleagues are coding. And then reimbursement strategies, as I mentioned before, is this risk-adjusted health plans. So revenue cycle, I had mentioned alpha and numeric language translated into the payment. American Medical Association is the proprietary owner or copyright for CPT codes, which is called the Current Procedural Codes. And examples are your outpatient visits, an example of the 99214 or new patient visit 99204. And here's a CPT code for a colonoscopy. HCPC codes stand for Healthcare Common Procedural Coding System. These codes are acknowledged by CMS. So these are codes that you would only use if your patient was Medicare fee-for-service or Medicare Advantage code. So here are two codes for screening colonoscopy, whether it's high risk or not at high risk. And then these are two codes that I'll be mentioning today that are new for 2024. One is G2211, which is Moderate Complexity Add-on Code. So this code is used if you are continuing care and you need to provide care for a patient that you expect that they'll be coming back and that they need your services. Then social determinants assessment is a code that you use to assess the patient for social determinants, which you'll see now, you've noticed over the last several years, there are now ICD-10 codes that we can code for acknowledging if a patient is homeless or has food insecurity. But this assessment code has to include a plan. So you can't just have the patient fill out this assessment sheet before they come into the office. It has to be real time that you deem that they need to have some type of assessment performed. This is another schematic drawing of a difference between ICD-10 code, a CPT code, and a modifier. An example of a modifier that you're going to include with your visit, which is literally our transaction that day, the modifier 25 is telling the payer through a billing system, translating through the language through the computer, that you had an office visit today, 99214. You did an anoscopy and you're adding the 25 because you want to be reimbursed completely for both procedures versus have a reduction in that cost. So it's a way of a language for explaining to the payer what you expect in reimbursement. This is an example of coding to the highest principle. Several years ago, we had one code for irritable bowel syndrome. Now we have multiple codes that can help differentiate the different symptoms or state that your patient is in at that time. And then also we'll discuss about codes that you add on that clinically impacts your decision-making. The coding guidelines are very clear that they do not expect that we submit a laundry list of all the different codes that we want to include on our bill that day to be able to then show there's medical necessity and we want to bill at that higher level, say a 99214, 99215. But as Dr. Vicari mentioned in that scenario before, this impacts our care. If we're seeing a patient in the office that's having rectal bleeding and potentially burgundy stool, well, if they're on an anticoagulant and they have a history and they're morbidly obese and you anticipate that you're going to have to coordinate an urgent procedure and that their BMI is over 40 and they need an anesthesiologist, you're creating a scenario that this patient is a higher acuity and that there's more work involved, cognitive work and resources in your office. I wanted to go over with you a list of tabula list. These are tabula lists of codes that are relevant and that you'll see that are appropriate that we use in our day-to-day practice for gastroenterology. These are new codes for 2024. Small intestinal bacteria overgrowth has now given us specific codes and intestinal methanogenic overgrowth as well. So now we can actually code the specific type when we get the test back, whether it's hydrogen specific, sulfide, or if there's a methane involved. And then also new codes for this year were short bowel syndrome, whether it's identified with colon in continuity or without the colon. And this is a list of examples of social determinants of health. And I wanted to just highlight several new ones that were for this year. And I'll give you that as a resource. And these are additional ones. So problems related to housing and economics, inadequate housing. And you'll see when we go over the E&M, the evaluation management guidelines, social determinants of health is one of the factors that if it's included in your decision-making that it's considered moderate complexity, which is part of your 99214 services. So the new add-on code, the G2211, this is a code that you would add on if you find that there's complexity enough in the patient visit that you need to bring them back again to provide additional services. So this also includes medical management. So if you're bringing a patient back in again, and say, if you're managing their visit, whether it's for a new patient, whether it's for inflammatory bowel disease, where you're trying to help manage their care, you're bringing them back in again, you're seeing them back for a follow-up for their colonoscopy and their biologics and routine blood work. This shows that there's a continuity of care and that you can bring that patient back in again, because you're continuing that care. It's not a one and done. Now your one and done is your office visits, your 99213. These are patients that you're seeing in follow-up visit. And this is one of the codes that a lot of people were saying that they were coding in their office. This is someone that you've seen back again, that they're stable, you're managing their bowel movements, they have chronic constipation, and you're saying, continue with the current high fiber diet that you're on, you've been responding well, no reason to follow up, please contact my office if you need any other follow-up from us. So that type of relationship is a visit that say you would not add this code on because you don't expect to see them back again. But we certainly see many complex patients in our office, whether it's a follow-up visit for alcoholic cirrhotic with cirrhosis, whether it's a follow-up for a patient that's coming back in that's having a flare of their ulcerative colitis, whether a patient's coming in and they have eosinophilic esophagitis and having recurrent dysphagia. So these are patients that you're seeing back again for follow-up to make sure that the care that you're providing is working for your patients. And this is the social determinants of health risk assessment tool. So it's five to 15 minutes, you don't want to do it more than once every six months. And this is a great website, CMS, I really have to applaud CMS for providing so many more educational resources than they ever had for coding and billing and also for new codes. So the 2024 split shared visit guidelines, this has been changed and this has certainly been kicked around for a long time. How do we separate out the difference between the work of the advanced practice provider and the work of the physician in the inpatient setting? Or it's not only inpatient setting, but some type of hospital setting or emergency room setting. So they've identified that they're using the terminology substantive portion of the encounter that either it differentiates. So who's going to bill for this? You have two people that are working hard on taking care of this patient and we each have our strengths and how we help take care of this patient visit. So either can be billed on substantive portion of the encounter or time-based counter. So spent the majority of the face-to-face time, and this is the total time on the date of the encounter that you'll see. And so it maps out that the purpose of the reporting E&M services in the context of the team-based care, it's either substance in part of your medical decision-making, which requires that the patient or QHP made or approved the management plan for the number and complexity of problems addressing at the counter and takes responsibility for that plan. And that's what inherent to the risk and complications of the morbidity mentality. Now by doing so, a physician or other QHP has performed two of the three elements used in the section of the code level based on medical decision-making. So you have three sections of your medical decision-making. You have your your problems, you have the amount of data that you've collected, and then you have that complexity of the data that you've processed. So I'm one of the delegates for the American Nurses Association, and we sit on a committee where we monitor the visits, the new visits that come in, and looking at the new language. So the American Academy of Physicians Associates was present, the American Nurses Associations were present too to make sure that we had our input and how to make sure that we also have an opportunity to be able to code and bill for these services. So this is an overview of the E&M CPT codes. So previously in the 1995 and 1997 guidelines, it was very specific and very prescriptive on how to code for a visit. We had to have exact bullets for history, we had to have an exact bullet for a physical exam, and I loved how Dr. Bakari went over that earlier because sometimes I'm worried that we're going to lose that because it actually made for a good visit to provide great care for patients because you had to have the old cart, you had to have so many bullets. But so it's now changed now that it's the determining that complex medical decision-making is now going to be determined either straightforward, low complexity, moderate complexity, or high complexity. So there are three components, we don't need two out of three anymore. I think one point that I do want to emphasize is that determining which level of service that you use is going to be based on whether it's a new or established patient, it's going to be based on whether you've seen that patient in your specialty, not just you, but in your specialty, either it's under three years or over three years. So that's how you're going to know which level that you're going to start to code. And these are the guidelines for 2021, you're looking at the medical decision-making as you're overarching. And then also you have total time that you're able to use, and I'll show you the update for the time factors as well. So again, it's broken down your type of decision-making, a number of diagnoses, amount of complexity and the risk of significant complications. So what I want to highlight you to, and I don't want, they say, I don't want to lead you or drive you to upcoding because it certainly is not upcoding. We work hard taking care of our patients and they're complex. So if you look at the 99214, it's, you have the number of diagnoses and management options. So that's moderate. You look at the testing. So one out of the three categories. So you're ordering a test, you're reviewing a test. So, or you're discussing a management or interpretation of a test and then moderate risk is prescription drug management. So if you're writing a new prescription and going over the risk and benefits and the side effects, that's drug management. Also looking at diagnosing a treatment limiting, limited by social determinants. So social determinants also can be if patients are not compliant with their medication. If you go back and you find out that you did recommend, say if a patient has, has proctitis and you had recommended that they used misalamine enemas for six weeks, and they only used it for two days and they're back in your office, erectile bleeding, you know, there are social determinants that of health, the Z-codes that you can, you can write that patients are having problems. Either it was, why did they not follow your care? Is it because that they didn't have transportation to pick up their prescription? They didn't have the funds to pick up the, the, the medication. These are things that you start to uncover that we're really good at in talking to our patients and finding out about these problems. The, the, the challenges is then looking for that code, but usually with your EMR systems, you can go ahead and search that, find it. And then your high-risk patients, intensive prescription monitoring, managing toxicities. These are all our patients that are high-risk patients are alcohol, cirrhotic patients, and our patients who are on, who are on biologics. So you need two out of these three categories to meet your medical decision-making. So you have, if you're looking at ordering labs, and if you're looking at moderate, moderate risk, then you're in this region here, your moderate complexity. If you have to think about your patient and, and change your medical decision-making or identify risks that the patient is at, this will give you a moderate complexity. And then this 2024 the new guidelines state that you don't need to meet within a range anymore, just a threshold. If you go over that time definition of time, this is really important. This was a new change that came up with the 2021 guidelines, and you can count the amount of time from the time you open up that same data service, the time you open up the chart and you start doing your pre-work to the end of the day, when you close your note. So you can do time-based coding using that strategy. And these are bullet points of what you can include in that. They're coding elements. I had mentioned earlier about the difference between different payer options and this, anyone who does prior authorizations or does peer-to-peers, you're, you're very familiar with how different payers require different guidelines and different specific documentation to authorize for those services. And as Sarah mentioned, I think we're becoming more and more important to step in to, to take care of those processes. Just the other day, I was asked to speak to an insurance company, one of the prior authorization companies, because our gastroenterologist, she was at a hospitalist that day and she was in a complex procedure and they had denied the CT scan. They needed more information. So I stepped in, read the chart and then, you know, you do your thing. So this is an example also that Dr. Vicari had mentioned that we have to be articulate with understanding the guidelines because the insurance companies are, and the third payers are as well. So they know our guidelines very well. So if we're ordering a test that doesn't follow the guidelines, that's why that they're going to question it and, or deny it or require a prior authorization. I've started to embrace it now. I think it's a challenge. So practice pearls. One of the things that you can help you get through your day and open, and open your note, complete your documentation to close it, is to develop some visual cues and reminders near your computer to help you identify those keywords of documentation. Develop templates to optimize capturing data, look at your workflows, ensure the ancillary staff is doing what they can do, request your coding team to perform a sample audit and perform peer-to-peer clinical documentation reviews, which is an excellent time, as Sarah was mentioning, during your onboarding to redo that clinical documentation. So in summary, code to your highest specificity. You want to provide accurate documentation to tell the patient's story. Look at your medical decision-making is based on two of those three components. Utilize the new social determinants of health codes. Understand split shared. Now you can look at substantive time or time spent and your 2024 time-based guidings. Coding guidelines are based on meeting that time threshold now. And these are some references. I encourage you to use them. Again, CMS has some great references, even including basic evaluation and management services. Thank you.

nurse practitioner

gastroenterology

billing and coding

reimbursement

evaluation and management coding

social determinants of health